Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on June 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary, and the enrollee was treated on scene. The Plan denied your request. 
The Plan says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on June 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for L5 and S1. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The appellant says the science supports the safety and effectiveness of 
the procedure. The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. 
The Plan says the lumbar magnetic resonance imaging (MRI) does not show Modic endplate changes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no Modic changes on the magnetic resonance imaging (MRI). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure for L5 and S1.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable ambulance supplies provided on September 
16, 2022. 
 You asked the Plan to pay for the disposable supplies. You say that you do not agree with the denial. The Plan 
denied your request. The Plan says the payment for this service was included in the fee for the ambulance 
services.  
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the disposable ambulance supplies provided on September 
16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on July 18, 2023. 
 
You asked the Plan to pay for gingival irrigation. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) provided on July 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you fell and needed help getting up and there was no need for transport. The Plan denied your request. The 
Plan says without transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on July 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport services provided on June 29, 2023. 
 You asked the Plan to pay for the ambulance transport services. You say that the enrollee ended hospice before 
the services were provided. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 5, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance transport 
services provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) and gingival 
irrigation (D4921) provided on July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the periodontal scaling and root planing has already been exhausted. 
Gingival irrigation is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the periodontal scaling and root planing was exhausted on date of service January 13, 2023. Gingival irrigation is not a covered service. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing (D4342) and gingival irrigation (D4921) provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
on August 24, 2023. 
 
You asked the Plan to pay for the bitewings. The Plan denied your request. The Plan says your benefit for the 
requested bitewings has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service February 16, 2023. Therefore, 
we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
on August 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary for you to receive help getting up after a fall. The Plan denied your 
request. The Plan says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture and interpretation with limited field 
of view (D0364) provided on May 9, 2023. 
 
You asked the Plan to pay for a cone beam CT capture and interpretation with limited field of view (D0364). 
You say that there is no reason for the Plan to exclude this service from the dental coverage. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam computed tomography (CT) capture and interpretation with limited field of view (D0364) provided on 
May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for splint - extra-coronal; natural teeth or prosthetic crowns 
(D4323), and tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth (D7270) 
provided on October 2, 2022. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for splint - 
extra-coronal; natural teeth or prosthetic crowns (D4323), and tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth (D7270) provided on October 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) provided on December 15, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that you spoke with the 
provider regarding a painful toothache you were experiencing who encouraged you to undergo a cleaning as 
you had not had one in 20 years. You also say that you decided to proceed despite being unsure if the services 
would be covered. The Plan denied your request. The Plan says this service is not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on August 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 24, 2023. Therefore, 
we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820) provided on July 6, 2023. 
 
You asked the Plan to pay for the interim partial denture. You say that you are having a problem with eating 
and speaking properly and you cannot wait five years to be able to get another partial. The Plan denied your 
request. The Plan says your benefit for the requested interim partial denture has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service March 22, 2022.  Therefore, we decided that the Plan does not have to pay for the interim partial denture (including 
retentive/clasping materials, rests, and teeth), maxillary (D5820) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral comprehensive series of radiograph images (D0210) 
provided on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 16, 2020. 
Therefore, we decided that the Plan does not have to pay for intraoral comprehensive series of radiograph images (D0210) provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
and prophylaxis - adult (D1110) provided on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that these claims should be processed as we are in-
network providers for the plan. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided 
on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous hearing services (V5299) provided from 
January 30, 2023, to February 16, 2023. 
 
You asked the Plan to pay for miscellaneous hearing services (V5299). You say that you pay for this insurance, 
and it should cover all the office calls. The Plan denied your request. The Plan says services received from an 
out-of-network hearing network provider are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing services are obtained with a Plan hearing nationwide network provider.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of miscellaneous hearing services (V5299) have not been met. Therefore, we decided that the Plan 
does not have to pay for miscellaneous hearing services (V5299) provided from January 30, 2023, to February 
16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on July 11, 2023. 
 
You asked the Plan to pay for hearing aids (V5261). You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not registered 
in advance. The Plan also says that hearing aids ordered through providers of then the Plan hearing are not 
covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing services are obtained through a Plan hearing nationwide network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5261) provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation-problem focused (D0140) 
and the dental cleaning (D1110) provided on August 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.   
 
 
 
 
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation-problem focused 
(D0140) and the dental cleaning (D1110) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on May 11, 2023. 
 
You asked the Plan to pay more for the dental services. You say that if you knew the provider was out of 
network you wouldn't have gone there. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the extraction of an erupted tooth (D7140) provided on 
March 31, 2023. 
 
You asked the Plan to reimburse for the dental services. You say that the Plan sent you a form telling you to 
complete and send back to them, and you would be reimbursed the $200. The Plan denied your request. The 
Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to reimburse for the extraction of an erupted tooth (D7140) provided on March 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on February 11, 2023, 
to, February 14, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the enrollee does not feel responsible 
for the charges because the hospital should have known what medications to give that would be covered. The 
Plan denied your request. The Plan says that self-administered drugs do not fall under the Medicare Part B 
coverage.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on February 11, 2023, to, February 14, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.