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

 
We decided that the Plan does not have to pay for nursing facility care provided on February 22, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on February 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on January 18, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
January 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on January 20, 2023. 
 
You asked the Plan to pay for emergency room services. You say that you are requesting reconsideration for 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for emergency room 
services provided on January 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 30, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a fixed income 
and cannot afford this payment. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for the ambulance services. This item/service falls within the 
ambulance 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 waive the copayment for the ambulance 
services provided on November 30, 2022.
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 November 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
enrollee should not have to be responsible for the ambulance claim as there was no transport and the insurance 
company should pay it for her. 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 November 3, 2022. 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 November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) and the x-ray exam of the 
lumbosacral spine (72100) provided on February 7, 2023. 
 
You asked the Plan to pay for these 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 services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99212) and the x-ray exam of the lumbosacral spine 
(72100) provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on April 21, 2021. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that bitewings x-
rays are a covered benefit, so the full mouth series of x-rays should be a covered benefit.  The Plan denied your 
request. The Plan says x-rays are not covered benefits of your dental 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 an 
intraoral - complete series of radiographic images (D0210) provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3348), 
provided on February 16, 2023. 
 
You asked the Plan to pre-approve D3348. You say that this dental work was medically necessary. The Plan 
denied your request. The Plan says the rendered dental service 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 pre-approve a 
retreatment of previous root canal therapy (D3348), provided on February 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance mileage provided on February 4, 2023, and 
March 9, 2023. 
 
You asked the Plan to pay for the ambulance mileage. You say that you requested to be transported to this 
hospital. You also say that the closest hospital does not provide adequate care for your complex health issues 
and you have had poor experiences in the past. The Plan denied your request. The Plan says traveling beyond 
the nearest facility is not a Medicare-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that only ambulance mileage to the nearest 
appropriate facility equipped to treat the patient is covered. 
 
We looked at the file and Medicare rules. You asked the Plan to pay for the ambulance mileage. Based on this 
information, we decided that Medicare rules for coverage of the non-covered ambulance mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance mileage provided on February 4, 
2023, and March 9, 2023.  
 
Your complaint about your poor experiences with the hospital is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and an adjunctive pre-diagnostic test 
(D0210, D0431) provided on February 7, 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 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 April 19, 2019 (D0210). 
This benefit does not include adjunctive pre-diagnostic tests. Therefore, we decided that the Plan does not have 
to pay for an intraoral x-ray and an adjunctive pre-diagnostic test (D0210, D0431) provided on February 7, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) and localized 
delivery of antimicrobial agents (D4381) provided on February 9, 2023, to February 15, 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. 
 
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. Therefore, we decided that the Plan does 
not have to pay for periodontal scaling and root planing (D4341) and localized delivery of antimicrobial agents (D4381) provided on February 9, 2023, to February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG and outpatient hospital 
observation services provided on February 24, 2023. 
 
You asked the Plan to waive the copayment for the EKG and outpatient hospital observation services. You say 
that you have had this done many times and have only had to pay a $50 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 $50 
copayment for outpatient diagnostic tests. Your contract with the Plan clearly also says that you must pay a $300 copayment for in-network outpatient hospital observation services. 
 
You have been asked to pay a $50 copayment for the EKG. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. You have also been asked to pay $115.18, which is 
less than the standard $300 copayment for the outpatient observation services. This item/service falls within the 
outpatient hospital observation benefit category. You have been asked to pay a total of $165.18 ($50 
copayment + $115.18 copayment = $165.18). 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 EKG 
and outpatient hospital observation services provided on February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental services on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified adjunctive procedure (D9999). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot go without a front tooth or pay 
a $3,000 bill. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental 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 pre-approve an 
unspecified adjunctive procedure (D9999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the dental implant 
removal (D6100), and the bone replacement graft (D7953) for tooth #30 provided on July 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were an emergency, and 
you would like the Plan to cover them. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the guided tissue regeneration, the dental implant removal, and the bone 
replacement graft are 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 the 
guided tissue regeneration (D4266), the dental implant removal (D6100), and the bone replacement graft 
(D7953) for tooth #30 provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 9, 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 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 11, 2022, and 
November 23, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) provided on November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 chiropractic manipulative treatments (98941) to be 
rendered by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says in-network providers are available to render the 
requested services.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 12 
chiropractic manipulative treatments (98941) 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 pre-approve a mandibular partial denture. 
 
You asked the Plan to pre-approve the dental services. You say that it is hard to eat without this denture. 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 2, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown on tooth #3 (D6740). 
 
You asked the Plan to pre-approve the dental services. You say that you have not met your annual dental 
benefit for the year. The Plan denied your request. The Plan says that your dental benefit only covers services 
up to $1,000 per calendar year. 
 
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 applied your $1,000 dental benefit to the requested services on this prior authorization. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown on tooth #3 (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary/mandibular dentures (D5110, 
D5120). 
 
You asked the Plan to pre-approve 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 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 January 28, 2019. 
Therefore, we decided that the Plan does not have to pre-approve complete maxillary/mandibular dentures 
(D5110, D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone 
replacement graft (D7953) for tooth #19 provided by on January 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that the services would not 
be covered, and you would like the Plan to reconsider paying for the dental services. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the guided tissue 
regeneration and the bone replacement graft are 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 the 
guided tissue regeneration (D4266) and the bone replacement graft (D7953) for tooth #19 provided by on 
January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that you would like the Plan to approve this 
CGM. The Plan denied your request. The Plan says a Freestyle Libre 3 is not a covered device. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).