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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 10, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that once the 
paramedics solved your medical issue you felt that there was no need to go to the emergency room. You also 
say that if you had gone to the emergency room that would have been a high cost to the health plan. 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 February 10, 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 February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x 2); gingival 
irrigation (D4921 x2) and periodontal procedure (D4999x2) provided on March 21, 2023. 
 
You asked the Plan to pay for gingival irrigation, and periodontal procedure. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. Periodontal scaling and root 
planing is allowed but does have a $45 copayment per quadrant.   
 
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 periodontal scaling and root planing (D4341 x 2); gingival irrigation (D4921 x2) and periodontal procedure 
(D4999x2) provided on March 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
performed at an outpatient hospital provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI) performed at an outpatient 
hospital. You say that this procedure was authorized and you would not have received it if you knew it was not 
covered in full. 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 for outpatient diagnostic test. 
 
You have been asked to pay a $295 copayment for a magnetic resonance image (MRI) performed at an 
outpatient hospital. This item/service falls within the outpatient diagnostic test 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. The total you owe is $237.86, which is 
less than the standard copayment for an MRI performed at an outpatient hospital. Therefore, we decided that 
the Plan does not have to waive the copayment for a magnetic resonance image (MRI) performed at an 
outpatient hospital provided on April 11, 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 March 1, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the provider should only bill you for what the 
Plan allowed during your previous dental visit. 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 the Plan paid for a limited oral evaluation (D0140) on February 28, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of February 28, 2023. Therefore, we decided 
that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 1, 2023.  
 
Your complaint about what the provider is billing and what the Plans allowable amount for the dental service 
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: 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 August 17, 2021. 
 
You asked the Plan to pay for ambulance services and ground mileage. You say that you are requesting 
reconsideration of the claim as it was submitted timely but to the wrong insurance carrier. The Plan denied your 
request. The Plan says the claim was untimely, and the submission did not meet the exception criteria 
guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for ambulance services and ground mileage was not filed until March 11, 2023. 
This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency 
transport and ground mileage provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (J0690) and home infusion therapy provided on 
September 30, 2020. 
 
You asked the Plan to pay for an injection and home infusion therapy. The Plan denied your request. The Plan 
says the claim was denied as timely filing. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
  The record shows that a claim for an injection and home infusion therapy was not filed until March 7, 2023. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an injection (J0690) and home infusion therapy 
provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination and a 
determination of refractive state provided on May 02, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination and a determination of refractive 
state. You say that this was a Medicare vision test only appointment. 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 $45 
copayment for Medicare-covered examination to diagnose and treat diseases or conditions of the eye. 
 
You have been asked to pay a $45 copayment for a medical eye examination and a determination of refractive state. This item/service falls within the Medicare-covered examination to diagnose and treat diseases or 
conditions of the eye 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 a medical eye 
examination and a determination of refractive state provided on May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body (D6010), the extraction 
of an erupted tooth (D7140) and a bone replacement graft for ridge preservation (D7953) provided on January 
27, 2023.  
 
You asked the Plan to pay for the dental services. You say that you were unaware of your dental benefits; 
therefore, you used an out-of-network specialist. 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 surgical placement of implant body (D6010), the extraction of an erupted tooth (D7140) and a bone 
replacement graft for ridge preservation (D7953) provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial lower denture (D5214) for tooth #28 provided on 
February 23, 2023. 
 
You asked the Plan to pay for the dental service. You say that your previous denture did not fit right and the 
previous provider could not fix it. 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 the Plan paid for a lower partial denture (D5214) for tooth #28 on January 4, 2023; therefore, your 
benefit for the requested item or service was exhausted on date of service January 4, 2023. Therefore, we 
decided that the Plan does not have to pay for a partial lower denture (D5214) for tooth #28 provided on 
February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 23, 
2023. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like to be reimbursed for 
the periodontal services in dispute, as that is how the provider cleans your teeth now. The Plan denied your 
request. The Plan says periodontal maintenance is not a covered procedure. 
 
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 
periodontal maintenance (D4910) provided on March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says ongoing skilled care could be provided in an alternative setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 2, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says 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 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve cataract surgery. You say that you would like to use a doctor who is very 
experienced. The Plan denied your request. The Plan says the requested services can be provided by a 
participating 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 
cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI to be provided by an OON provider.  
 
You asked the Plan to pre-approve an MRI. You say that you do not agree with the denial of the MRI at the 
facility you feel is best. The Plan denied your request. The Plan says the 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 
an MRI to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lasik surgery. 
 
You asked the Plan to pay for Lasik surgery. You say that Lasik surgery would greatly benefit the enrollee. The 
Plan denied your request. The Plan says Lasik surgery is not covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that while traditional cataract surgery is fully covered 
by most private medical insurance and Medicare, bladeless cataract surgery requires patients to pay out-of-
pocket for the portion of the procedure that insurance does not cover.  
We looked at the file and Medicare rules. Based on this information, Lasik surgery is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for Lasik surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on September 30, 
2022. 
 
You asked the Plan to pay for periodontal maintenance (D4910). You say that you are diabetic, and it is 
recommended she have her teeth cleaned more often than non-diabetics. The Plan denied your request. The 
Plan says charges for dental related services are excluded from coverage under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride and periodontal maintenance 
(D4910, D1208) provided on January 16, 2023, by an out-of-network (OON) provider. 
 
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 the application of fluoride and periodontal maintenance (D4910, D1208) provided on January 16, 
2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain stem. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee is showing symptoms of memory loss 
and seizures. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
service is medically necessary. Our physician reviewer found it is a standard of practice/care to have MRI 
performed in the initial evaluation of cognitive impairment/dementia. Such imaging is done to rule in/out any 
intracranial process as the cause of memory difficulties. In such a setting it can be said that this service would 
be consistent with standards of care/practice. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain stem.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for core buildup, including any pins when required 
(D2950), and crown - porcelain/ceramic (D2740) provided on March 20, 2023. 
 
You asked the Plan to pay more for the core buildup and crown - porcelain/ceramic. You say that you were not 
informed of the difference between the two policies in dental coverage. You also say that you should not be 
charged for this service since it would have been previously covered under the policy that was effective 
through February. The Plan denied your request. The Plan says your benefit for the core buildup and crown - 
porcelain/ceramic $1,500 dollar limit was met. 
 
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 core buildup and crown - porcelain/ceramic was exhausted on dates of service 
January 6, 2023, and February 6, 2023. Therefore, we decided that the Plan does not have to pay more for core 
buildup, including any pins when required (D2950), and crown - porcelain/ceramic (D2740) provided on 
March 20, 2023.