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

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images obtained intra-orally 
or extra-orally (D0350) provided on April 6, 2023. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you don't have the money 
to pay for these pictures as you don't work. You also say that you think the dentist was wrong not to  have 
asked if the plan would cover these images. The Plan denied your request. The Plan says you had a dental 
service that is not listed in the dental guide. 
 
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 2D oral/facial 
photographic images obtained intra-orally or extra-orally (D0350) provided on April 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 16, 2023. 
 You asked the Plan to pay for the ambulance service and ground mileage. You say that you believe this 
ambulance transport was the only safe way to adequately transport the enrollee due to their medical condition. 
The Plan denied your request. The Plan says ambulance transport from an outpatient office or facility for a 
scheduled appointment is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on January 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found CT coronary calcium screening in an 
asymptomatic patient is not covered unless there is a calculated lifetime risk of atherosclerotic cardiovascular 
disease (ASCVD) of 5-19.9%. No such calculation is in the records. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced life support, level 2 transport and ground mileage 
provided on March 29, 2023. 
 You asked the Plan to pay for the advanced life support transport and ground mileage. You say that you are 
submitting supporting documents for review. 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 April 8, 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 advanced life support, level 
2 transport and ground mileage provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
images (D0220 and D0230), the bitewings (D0274), a cleaning (D1110), and the application of fluoride 
(D1208) provided by an out-of-network provider on February 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the broker told you that all your providers were 
in-network with the Plan and would like a courtesy payoff. 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 (D0120), the intraoral radiographic images (D0220 and D0230), the 
bitewings (D0274), a cleaning (D1110), and the application of fluoride (D1208) provided by an out-of-network 
provider on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 30, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you had no other dental claims for the year, so 
the calendar year maximum has not been met. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year 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 the Plan paid $328 for dental services on January 11, 2023. On January 18, 2023, the Plan paid $922 for 
dental services. For the year of 2023 the Plan paid $1,250 ($328  paid + $922 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
January 18, 2023. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), semi-precision attachment (D6052), and implant/abutment supported fixed denture (D6078). 
 
You asked the Plan to pre-approve the surgical placement of implant body, semi-precision attachment, and 
implant/abutment supported fixed denture. You say that there is no bone to hold the denture in place in the 
bottom of your mouth, you cannot eat and have lost 35  pounds.  The Plan denied your request. The Plan says 
these services are not covered under your dental 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of implant body: endosteal implant (D6010), semi-precision attachment (D6052), and 
implant/abutment supported fixed denture (D6078).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs, self-administered. 
 
You asked the Plan to pay for the medication. You say that  The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
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 drugs, self-administered.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home ventilator provided on December 12, 2021. 
 You asked the Plan to pay for the home ventilator. You say that the equipment was medically necessary. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a home ventilator provided on December 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and a fixed partial denture 
(D9120) provided on May 1, 2023, to May 9, 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 limited oral evaluation was exhausted on date of service February 9, 2023, and February 13, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation 
(D0140) and a fixed partial denture (D9120) provided on May 1, 2023, to May 9, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 12, 
2023, to February 10, 2023. 
 You asked the Plan to pay for the SNF care. You say that the services the enrollee received should be covered 
under the Medicare Act. The Plan denied your request. The Plan says the enrollee does not require SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from January 12, 2023, to February 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for PT and OT provided from October 26, 
2022, to December 21, 2022. 
 
You asked the Plan to reduce the copayment for PT and OT. You say that you are confused why you are being 
charged so much for a copayment and do not agree with the amount assessed. 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 $30 
copayment for each Medicare-covered occupational therapy visit and a $30 copayment for each Medicare-
covered physical therapy and/or speech and language pathology visit.  You have been asked to pay a $30 copayment for each PT visit and a $30 copayment for each OT visit. This 
item/service falls within the outpatient rehabilitation therapy services 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 reduce the copayment for PT and OT provided from October 26, 2022, to December 21, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on March 24, 2023. 
 You asked the Plan to pay for inpatient hospital care. You say that the enrollee was not enrolled in hospice 
during date of service at issue. 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 March 13, 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 inpatient hospital 
care provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) and miscellaneous (V2799) 
provided on March 3, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781) and miscellaneous (V2799). You say that this is the 
only vision provider in your area. The Plan denied your request. The Plan says your benefit plan does not cover 
out-of-network vision care. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are provided in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $100 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses (one per calendar year). The Plan contract also says that any benefits 
received at a non-network optical provider are excluded from this benefit. The record shows there are in-
network vision providers in your area. Based on this information, we decided that the Plan's rules for coverage 
of progressive lenses (V2781) and miscellaneous (V2799) have not been met. Therefore, we decided that the 
Plan does not have to pay for progressive lenses (V2781) and miscellaneous (V2799) provided on March 3, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that a PET scan is medically necessary for the 
enrollee's diagnosis. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not noted to meet the 
diagnostic criteria for AD or FTD. Therefore, the enrollee does not meet the base requirements for coverage of 
the requested service. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home use of oxygen and oxygen tanks (E1390, E0443, 
and E0431). 
 
You asked the Plan to pre-approve home use of oxygen and oxygen tanks. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of home use of oxygen and oxygen tanks 
have been met. Specifically, documentation to support the requested items was requested but not received. 
Medical necessity cannot be established without this documentation. Therefore, we decided that the Plan does 
not have to pre-approve home use of oxygen and oxygen tanks (E1390, E0443, and E0431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), a cone beam (D0364), 
the pulp vitality test (D0460), the removal of residual tooth root (D7250), the bone replacement graft (D7953), 
and anesthesia (D9215) for tooth #14 provided by The Wheelchair Store on January 5, 2023, January 9, 2023, 
and January 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told if you had dental surgery that 
Medicare would cover the claim. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because dental implants are the only dental procedures 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, 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 the 
limited oral evaluation (D0140), a cone beam (D0364), the pulp vitality test (D0460), the removal of residual 
tooth root (D7250), the bone replacement graft (D7953), and anesthesia (D9215) for tooth #14 provided by The 
Wheelchair Store on January 5, 2023, January 9, 2023, and January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) on 4 quadrants provided on April 
11, 2023, and April 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the deep cleanings are covered, and you should 
be reimbursed the cost. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the gingival irrigation 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, 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) on 4 quadrants provided on April 11, 2023, and April 19, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, lesion destruction, and biopsy provided on 
July 12, 2022. 
 You asked the Plan to pay for the office visit, lesion destruction, and biopsy. You say that the services were 
medically necessary. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit, lesion destruction, and biopsy provided on 
July 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (93970) provided on March 7, 2023. 
 
You asked the Plan to pay for the radiology services. You say that this service was 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 93970 is not supported in the medical record. Specifically, multiple units were billed 
for a service that is bilateral. Based on this information, we decided that Medicare rules for coverage of the 
radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology 
services (93970) provided on March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics provided on February 14, 2023. 
 
You asked the Plan to pay for foot orthotics. You say that you are appealing the service that was dated for 
January 24, 2023, and not the Medicare coverage. The Plan denied your request. The Plan says this item is not 
a covered benefit. Also, medical records confirmed services were rendered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics provided on February 
14, 2023.