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

 
We decided that the Plan has to pay for procedure code A0427 provided on March 8, 2023. 
 
You asked the Plan to pay for procedure code A0427. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported 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. In this case, the CPT Code Manual definition of 
code A0427 is Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency). 
 
We find that CPT code A0427 is supported in the medical record. Specifically, an ALS unit has at least one 
paramedic and is equipped with advanced airway equipment, a cardiac monitor/defibrillator, IV fluids, 
medications, and more. The file shows the ambulance services provided meet the definition of code A0427. 
Based on this information, we decided that Medicare rules for coverage of procedure code A0427 have been 
met. Therefore, we decided that the Plan has to pay for procedure code A0427 provided on March 8, 2023.  
 
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 for intraoral x-rays (D0220, D0230) provided on March 30, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral 
x-rays (D0220, D0230) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  surgical removal of implant body (D6100), bone 
replacement graft (D7953) and surgical placement of implant body (D6010) provided on March 15, 2023. 
 
You asked the Plan to pay for  surgical removal of implant body and bone replacement graft. 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  surgical 
removal of implant body (D6100), bone replacement graft (D7953) and surgical placement of implant body 
(D6010) provided on March 15, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic angiography (CTA) of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the CTA. You say that the records provided support medical necessity. 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 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 CTA. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has had prior endovascular repair of 
an abdominal aortic aneurysm (AAA) as well as left popliteal to right femoral bypass graft. The last CTA 
abdomen and pelvis was on July 5, 2022. The request for a one-year surveillance is reasonable and should be 
approved. 
 
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 CTA have been met. Therefore, we decided that the Plan has to pre-approve 
a computed tomographic angiography (CTA) of the abdomen and pelvis.  
 
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 for polycarbonate lens (V2784) and anti-reflective coating 
(V2750) provided on April 3, 2023. 
 
You asked the Plan to pay for polycarbonate lens (V2784) and anti-reflective coating (V2750). You say that 
you were told the service would be $47 out-of-pocket, but you got a denial because of the coating. The Plan 
denied your request. The Plan says these service codes are not a covered service. 
 
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 one set of lenses every calendar year, which includes basic single vision, lined 
bifocal, lined trifocal, and lenticular lenses only. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one set of lenses every calendar 
year, which includes basic single vision, lined bifocal, lined trifocal, and lenticular lenses only. The Plan 
contract also says that additional upgrades, extra charges and/or any customizations are not covered, which 
include tinting, coatings, and/or special lens materials). Based on this information, we decided that the Plan's 
rules for coverage of polycarbonate lens (V2784) and anti-reflective coating (V2750) have not been met. 
Therefore, we decided that the Plan does not have to pay for polycarbonate lens (V2784) and anti-reflective 
coating (V2750) provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service March 8, 2021. Specifically, the 
Plans contract states that one complete upper denture is covered every 60 months. You previously received 
this dental item on March 8, 2021, less than 60 months prior, which was paid for by the Plan.   
 
 
 
 
Therefore, you have exhausted the allowable benefit for the requested item in this case. Therefore, we decided 
that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on March 30, 2023, to April 5, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 pay more for dental services provided on March 30, 2023, 
to April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 7, 2022. 
 
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 services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, panoramic x-ray, 
and fillings (D2393, D0330, D0140, D0220) provided on November 18, 2022, to December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 18, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, 
panoramic x-ray, and fillings (D2393, D0330, D0140, D0220) provided on November 18, 2022, to December 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says you have 
exhausted your transportation benefits.  
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 27, 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 
March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for seeing an 
out of network provider. 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 April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for  a crown  porcelain fused to high noble metal, on 
tooth #21 (D2750) provided on March 30, 2023. 
 
You asked the Plan to pay more for a crown. You say that you would like this to be covered in full. The Plan 
denied your request. The Plan says you pay 50% coinsurance after $100 deductible for Class 3 Major Services 
and if a method of treatment is more costly than is customarily provided, benefits will be paid on the least 
costly method of treatment, and you will be responsible for the remaining balance. 
 
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 among those covered under this benefit but if a method of treatment is more costly than is customarily 
provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the 
remaining balance. Therefore, we decided that the Plan does not have to pay more for  a crown  porcelain 
fused to high noble metal, on tooth #21 (D2750) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frame (V2020) and lenses (V2300) purchased on March 23, 
2023.  
You asked the Plan to pay for frame (V2020) and lenses (V2300). You say that you have been a member for 
over 20 years and are very pleased with the coverage provided. The Plan denied your request. The Plan says 
vision services must be provided by a contracted provider. 
 
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 they are obtained from an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules also say that vision services must be provided by a 
contracted provider. The record shows these services were obtained by an out-of-network provider. Based on 
this information, we decided that the Plan's rules for coverage of frame (V2020) and lenses (V2300) have not 
been met. Therefore, we decided that the Plan does not have to pay for frame (V2020) and lenses (V2300) 
purchased on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tympanometry (92567) and a 
comprehensive hearing test (92557) provided on April 3, 2023. 
 
You asked the Plan to waive the copayment for a tympanometry (92567) and a comprehensive hearing test 
(92557). You say that you are appealing with supporting records. 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 $35 
copayment for an examination to diagnose and treat hearing and balance issues. 
  You have been asked to pay a $35 copayment for a tympanometry (92567) and a comprehensive hearing test 
(92557). This item/service falls within the examination to diagnose and treat hearing and balance issues 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 record shows 
that his was a diagnostic test and not a routine hearing test. Therefore, we decided that the Plan does not have 
to waive the copayment for a tympanometry (92567) and a comprehensive hearing test (92557) provided on 
April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures you cannot wear 
because they put pressure on your jaw. 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 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 complete upper denture (D5110) and a complete lower denture (D5120) on January 
19, 2022; therefore, your benefit for the requested items or services was exhausted on the date of service of 
January 19, 2022. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interim caries arresting medicament application (D1354) 
provided on April 25, 2023. 
 
You asked the Plan to pay for interim caries arresting medicament application. 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 interim 
caries arresting medicament application (D1354) provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 99406, 94761, and 99072 provided 
on October 27, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 99406, 94761, and 99072. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met. 
 
In addition, procedure code 99406 is a timed code. In this case, the time spent on this procedure is not 
documented in the medical records. 
 
Furthermore, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99072 is not separately payable. We have also confirmed that procedure code 
94761 has a status indicator of T on the Physician Fee Schedule and was billed with other payable services 
under the physician fee schedule for the same date by the same provider. This means that procedure code 
94761 is not separately payable in this case. Based on this information, we decided that Medicare rules for 
coverage of codes 99072 and 94761 have not been met.  
 
Therefore, we decided that the Plan does not have to pay for procedure codes 87631, 99406, 94761, and 99072 
provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you are a pre diabetic and 
you need the sensors to be covered. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not have diabetes. Based on 
this information, we decided that Medicare rules for coverage of the supply allowance for the CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the supply allowance for a 
continuous glucose monitor (CGM).