Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and periodontal maintenance 
services provided on March 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 a periodic oral evaluation and periodontal maintenance services provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified procedure (D999) provided by an out-of-
network provider on February 18, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had an emergency procedure completed at a 
dental office while you were on a trip. 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. Also, the services 
were not performed in a hospital or an emergency facility. 
 
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 and the services 
were not completed in a hospital or an emergency facility. 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 an unspecified 
procedure (D999) provided by an out-of-network provider on February 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on November 12, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you are requesting 
reconsideration for services advising this was an emergency hospital to hospital transport to have sutures. This 
should be a covered benefit. The Plan denied your request. The Plan says the members claims history indicates 
that on this date of service the patient was in an inpatient hospital status. The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider 
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. Based on this information, we decided that Medicare rules 
for coverage of the ambulance service and ground mileage have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance service, basic life support, emergency transport and ground mileage 
provided on November 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified foot orthosis. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary 
 
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 brace. Our reviewer says that the 
requested brace is not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the requested ankle-foot orthosis is not specified. There is no documentation that the enrollee 
requires a custom-made orthosis, or a knee-stabilizing orthosis. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an unspecified foot orthosis.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2023, to 
January 30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that it was medically necessary to treat the 
enrollee and you did not get the denial in time. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no approved authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from January 
12, 2023, to January 30, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services, inhalation of nitrous oxide/analgesia, 
and a crown (D2950, D2740, D9230) provided on November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 core 
buildup services, inhalation of nitrous oxide/analgesia, and a crown (D2950, D2740, D9230) provided on 
November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #18 and #20 and the 
retainer crown (D6752) for tooth #20 provided on January 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to consider the 
porcelain under your coverage. The Plan denied your request. The Plan says your benefit for the retainer crown 
has already been exhausted. Also, the denial of payment for the core buildup is correct because it is not covered 
by the 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, certain limitations apply. The record 
shows your benefit for the retainer crown was exhausted on the date of service of January 5, 2023. The core 
buildup is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay 
for the core buildup (D2950) for tooth #18 and #20 and the retainer crown (D6752) for tooth #20 provided on 
January 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 21, 2023, to 
January 25, 2023 by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that the submitted medical records support the 
home health services were  medically necessary. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on January 21, 
2023, to January 25, 2023 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87496, 87500, 87511, 87529, 
87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87798) provided on December 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (87481, 87491, 87496, 87500, 87511, 
87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87798) provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) and the hearing 
aid check of both ears (92593) purchased on September 27, 2022. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these 
items/services are not payable as they were rendered by an out-of-network provider.  
 
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/services only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items/services have not been met. Specifically, the Plans contract says that hearing 
aids/services are only covered when purchased from the Plans select hearing aid provider. However, the 
hearing aids/services in this case were purchased from an out-of-network provider. Therefore, we decided that 
the Plan does not have to issue reimbursement for the hearing aids (V5261) and the hearing aid check of both 
ears (92593) purchased on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) provided on January 23, 2023. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you did not receive the 
dental plan information guide until February 20, 2023. You also say that you had no way of knowing was 
services are not covered. The Plan denied your request. The Plan says this service is not covered under the 
benefit package. 
 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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on January 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical consultation to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a surgical consultation. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the requested service can be 
provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a surgical consultation to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0425-HI-ET and A0434-HI-ET provided 
on November 26, 2022. 
 
You asked the Plan to pay for procedure codes A0425-HI-ET and A0434-HI-ET. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the claim, and Medicare rules. The file shows that the ET modifier billed with the 
ambulance codes is invalid. Therefore, we decided that the Plan does not have to pay for procedure codes 
A0425-HI-ET and A0434-HI-ET provided on November 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and a 20-degree 
active reach feature (K0108). 
 
You asked the Plan to pre-approve a seat elevation system and active reach feature. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
requested items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not primarily 
medically in nature. 
 
We looked at the file and Medicare rules. A power seat elevation system does not serve a medical purpose. A 
20-degree active reach feature is not covered without a power seat elevation system. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation system (E2300) and a 20-degree active reach 
feature (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid (V5298) purchased on 
October 7, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not payable as it was 
purchased from an out-of-network provider  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when purchased from the Plans select hearing aid provider. However, the hearing aid in this case was 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aid (V5298) purchased on October 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 15, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to the 
emergency room due to faulty lab results. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for in-network emergency care. 
 
You have been asked to pay a $120 copayment for the emergency room visit. This item/service falls within the 
in-network emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 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 waive the copayment for the 
emergency room visit provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) on all 
4 quadrants, the partial upper denture (D5213), and the partial lower denture (D5214) to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services and you would like for them to be approved. The Plan denied your request. The Plan says dental 
services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve the 
periodontal scaling and root planing (D4341) on all 4 quadrants, the partial upper denture (D5213), and the 
partial lower denture (D5214) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5261) to be rendered by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the items at issue are only covered when purchased from 
by the Plans select hearing aid provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, your request in this case is to 
purchase hearing aids from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pre-approve hearing aids (V5261) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided by The 
Wheelchair Store on March 20, 2023. 
 
You asked the Plan to pay for the dental service. You say that the x-ray was medically necessary to evaluate the 
progression of surgical sites and it should be covered by the Plan. 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 the date of service of March 29, 2022. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided by The Wheelchair Store on March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an in-network inpatient stay provided from November 08, 
2022, to November 10, 2022.   
 
You asked the Plan to reimburse an in-network inpatient stay . You say that you were required by the facility to 
be inpatient, it is not something you wanted. The Plan should reimburse that $590 copayment. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment each day for days 1 to 5 for Medicare-covered hospital care. You were inpatient for two days, 
resulting in a total $590 copayment ($295 x 2 days = $590 total). 
 
You have been asked to pay a $590 total copayment for an in-network inpatient stay.  This item/service falls within the Medicare-covered hospital care benefit category.  
This means that you have been asked to pay the correct amount based on your contract with the Plan. 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 reimburse an in-network inpatient stay provided from November 08, 2022, to 
November 10, 2022.