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

 
We decided that the Plan does not have to pay for chest x-rays provided on May 14, 2023. 
 You asked the Plan to pay for the x-rays. You say that the claim was submitted with the correct place of service 
code and should be paid. 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 chest x-rays provided on May 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee as they are unable to walk without assistance. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and does not require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code K0108 for date of service January 10, 2023. 
 
You asked the Plan to pay for code K0108. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the item provided in this case. Review of the file 
shows that the submitted medical records did not include a patient receipt or proof of delivery of the wheelchair 
component or accessory. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for code K0108 for 
date of service January 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on February 2, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for home visit. You say that authorization could not be obtained due to the patient 
misleading you with the incorrect insurance information. The Plan denied your request. The Plan says they 
have determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 visit provided on February 2, 2023, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin B-12 injection and levocarnitine provided on 
November 16, 2022. 
 
You asked the Plan to pay for the Vitamin B-12 injection and levocarnitine. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says the Vitamin B-12 injection and levocarnitine are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  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 the Vitamin B-12 injection and 
levocarnitine. Our reviewer says that the Vitamin B-12 injection and levocarnitine are not medically necessary. 
Our physician reviewer found that the requested use of the Vitamin B-12 injection and levocarnitine are not 
FDA-approved. The Vitamin B-12 injection and levocarnitine are also not supported by one of the major drug 
compendia or by clinical research. 
 
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 Vitamin B-12 injection and levocarnitine have not been met. Therefore, we 
decided that the Plan does not have to pay for the Vitamin B-12 injection and levocarnitine provided on 
November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for an adult prophylaxis (D1110) and a periodic oral 
evaluation (D0120) provided on June 15, 2023. 
 
You asked the Plan to reimburse more for the dental services. You say that you should be reimbursed at 100% 
of the billed charges.  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 reimburse more for an adult prophylaxis (D1110) and a 
periodic oral evaluation (D0120) provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  periodontal maintenance (D4910) 
provided on April 26, 2023. 
 
You asked the Plan to waive the coinsurance for  periodontal maintenance. You say that the wording was 
unclear and vague so it should be covered. 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 50% 
coinsurance for periodontal maintenance.  
 
You have been asked to pay 50% coinsurance for periodontal maintenance. This item/service falls within the 
periodontal maintenance 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 coinsurance for  
periodontal maintenance (D4910) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have had pain in your mouth. You also say 
you have sensitivity to hot and cold and pain in your mouth around teeth numbers 13 and 14. 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 March 22, 2023, and 
March 24, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on May 31, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 27, 2023. 
 You asked the Plan to pay for the ambulance services. You say that you do not work with the facility and the 
claim should be paid separately. 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 ambulance services provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal orthotic device (D7880) provided on June 27, 
2023. 
 
You asked the Plan to pay for an occlusal orthotic device (D7880). You say that you feel this should be covered 
because this was a medical necessity. 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 an 
occlusal orthotic device (D7880) provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
29, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were out of town, and this was an 
emergency. 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 dental services provided on February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), single vision sphere lenses (V2100) 
and anti-reflective coating (V2750) provided on April 8, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025), single vision sphere lenses (V2100) and anti-reflective 
coating (V2750). You say that you searched all the other providers that the Plan covers with the pricing of your 
prescription and frames. You also say that even with their discount the amount was not cheaper than what you 
paid for two pairs of glasses with this provider. The Plan denied your request. The Plan says according to the 
EOC, your mandatory supplemental vision Plan only covers in-network providers. 
 
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 eyewear is obtained through a Plan network optical provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of deluxe frames (V2025), single vision sphere lenses (V2100) and anti-reflective coating (V2750) 
have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), single 
vision sphere lenses (V2100) and anti-reflective coating (V2750) provided on April 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment - includes placement (D6057) 
and abutment supported porcelain/ceramic crown (D6058) provided on November 22, 2022. 
 
You asked the Plan to pay for custom fabricated abutment and abutment supported crown. You say that you 
thought this was 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 custom 
fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) 
provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endosteal implant (D6010) provided on April 5, 2023. 
 
You asked the Plan to pay for endosteal implant. 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 endosteal 
implant (D6010) provided on April 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 9, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that there was 
a 2 alarm fire located 2 doors down and you were led out of your apartment by a fireman for safety. You also 
say that due to the breathing of toxic smoke you were led to an ambulance to check your vitals and oxygen 
level. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 May 9, 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 with no 
transport provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical x-rays (D0220) and retainer crowns 
(D6752) for tooth #12 and (D6740) for tooth #10 and #12. 
 
You asked the Plan to pay for the dental services. You say that since the replacement tooth requires attachment 
to each adjacent tooth, you feel that the installation of the bridge including required attachments should be 
covered as one procedure. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 Plan's 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 x-rays (D0220) was exhausted on date of service February 6, 2023. The record also 
shows your benefit for the retainer crowns (D6752, D6740) was exhausted on February 20, 2023. Therefore, 
we decided that the Plan does not have to pay for intraoral-periapical x-rays (D0220) and retainer crowns 
(D6752) for tooth #12 and (D6740) for tooth #10 and #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens and the frames provided on January 18, 
2023. 
 
You asked the Plan to pay for the progressive lens and the frames. You say that the Plan never stated that the 
services had to be with in-network providers.  You say you have had eyeglasses made at the retail provider for 
years. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 received by network providers. 
 
We looked at the file and the Plan's rules. Specifically, the provider is not a network provider. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens and the frames have not been 
met. Therefore, we decided that the Plan does not have to pay for the progressive lens and the frames provided 
on January 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for registered nurse first assistant services provided on April 5, 
2023. 
 
You asked the Plan to pay for registered nurse first assistant services. You say that surgical assistance was 
required for this procedure. The Plan denied your request. The Plan says registered nurse first assistant services 
are not covered benefits. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for registered nurse first assistant 
services provided on April 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 14, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
husband fell at his residence and the staff called the paramedics. You also say that over the phone you spoke 
with the paramedics who informed you that your husbands vitals were good and didn't think he needed to be 
transported to the hospital. The Plan denied your request. The Plan says these services are not a covered 
benefit.  
 
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 April 14, 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 with no 
transport provided on April 14, 2023.