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

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation. 
 
You asked the Plan to pre-approve additional non-emergent transportation. You say that you had a stroke 
recently and not able to get around as easily. You also say that you have no one to assist you, and rely on the 
Plan transportation. The Plan denied your request. The Plan says transport requests for non-medical or non-
emergency medical transport are not covered past the allotted 24 transports. 
 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 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 non-emergent transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on August 31, 2022, to 
September 20, 2022. 
 
You asked the Plan to pay for the medication. You say that you would like to be reimbursed. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on August 31, 2022, to September 20, 2022.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective lenses (V2750) and polycarbonate lens 
(V2784) provided on July 18, 2023. 
 
You asked the Plan to pay for anti-reflective lenses (V2750) and polycarbonate lens (V2784). You say that you 
need your glasses. You also say that you are entitled to at least one pair. The Plan denied your request. The 
Plan says these are not a covered benefit. 
 
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 eye wear is standard and with no enhancements. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers standard eyeglasses, single 
vision or lined multi-focal lenses and frames. The Plan rules also say that enhancements are not covered 
through the allowance may be purchased by you at an additional cost. Based on this information, we decided 
that the Plan's rules for coverage of anti-reflective lenses (V2750) and polycarbonate lens (V2784) have not 
been met. Therefore, we decided that the Plan does not have to pay for anti-reflective lenses (V2750) and 
polycarbonate lens (V2784) provided on July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit, and lab services provided on 
June 19, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, and lab services. You say that the enrollee 
would like to continue to receive services at this location. 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 a hospital outpatient 
clinic visit, and lab services provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on July 3, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were advised by a plan representative that 
chiropractic services were covered, and you would be responsible for a $20 copayment. The Plan denied your 
request. The Plan says this is not a covered chiropractic service. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of an erupted tooth (D7210) for 
tooth #3 and the deep sedation (D9222 and D9223). 
 
You asked the Plan to pre-approve the dental services. You say that the sedation is medically necessary for the 
enrollee because their tooth is broken off. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the surgical removal of an erupted tooth and the deep 
sedation 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 pre-approve the 
surgical removal of an erupted tooth (D7210) for tooth #3 and the deep sedation (D9222 and D9223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020, L3031).  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit for your 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace that is an 
integral part of a covered shoe.   
 
 
 
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics 
for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020, 
L3031).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you only need 3 more trips for the rest of 
the year. The Plan denied your request. The Plan says the request for a 101st trip and beyond is not a covered 
benefit. 
 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 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 3 
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 (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on July 12, 2023. 
  
You asked the Plan to pay for the COVID-19 test. You say that you want to be reimbursed payment. The Plan 
denied your request. The Plan says the item is not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 09, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on February 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you do not have anyone to take you 
to your appointments you have already arranged. You also say you do not want to miss them. The Plan denied 
your request. The Plan says additional trips in excess of 34 one-way trips are non-covered by the Plan. 
 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 34 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 one-way trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided by a Licensed Professional 
Counselor (LPC) from June 8, 2023, to July 3, 2023. 
 
You asked the Plan to pay for the LPC services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says LPCs are not valid provider types for 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. LPCs are not permitted to 
bill Medicare for services rendered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LPC services have not been met. Therefore, we decided that the Plan does not have to pay for 
mental health services provided by a Licensed Professional Counselor (LPC) from June 8, 2023, to July 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular/maxillary dentures (D5110, D5120) 
provided on April 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within the enrollee's 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, fees for dentures provided by someone 
other than a dentist are a benefit exclusion. The records provided show that the dentures in dispute were 
provided by a denturist and not a dentist. Therefore, we decided that the Plan does not have to pay for complete 
mandibular/maxillary dentures (D5110, D5120) provided on April 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 18, 2023. 
 
You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says you did not bill with the correct Type of Bill 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 
Based on this rule, you should have billed this claim with Type of Bill 0329.  Instead, you incorrectly billed with Type of Bill 0323. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for in-network back injections provided on 
July 06, 2023. 
 
You asked the Plan to reduce the copayment for in-network back injections. You say that you have always only 
paid a $200 copayment, you feel like this larger copay is an error. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $350 copayment for in-network back injections. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for in-network back injections provided on July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that the previous denture is not working, and it 
falls out of your mouth. 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 partial lower denture (D5214) on May 2, 2019; therefore, your benefit for the 
requested item or service was exhausted on the date of service of May 2, 2019. Therefore, we decided that the 
Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 24, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that hospice has denied this claim, so the Plan 
should pay it. 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 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 9, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sneakers and Redi-thotics provided on July 28, 2023. 
 
You asked the Plan to pay for sneakers and Redi-thotics. You say that your provider recommended you 
purchase the Redi-thotics insert to be used with the footwear you purchased. The Plan denied your request. The 
Plan says these services are not covered by your contract. 
 The Plan must follow Medicare rules. Medicare does not pay for OTC items. Medicare rules also say that Plans 
may offer as a supplemental benefit health-related items and medications that are available without a 
prescription, and are not covered by Medicare. If the primary purpose of the item or service is comfort, 
cosmetic or daily maintenance, then it is not eligible as a supplemental benefit. Convenience and comfort 
items, as well as cosmetic items (such as skin moisturizers) are specifically listed as not being eligible for a 
supplemental OTC benefit. 
 
We looked at the file, Medicare rules and the Plan rules. The Plan rules say that the wellness benefit is for 
fitness and health related services. Sneakers and Redi-thotics are not covered under this benefit. Based on this 
information, we decided that Medicare rules for coverage of sneakers and Redi-thotics have not been met. 
Therefore, we decided that the Plan does not have to pay for sneakers and Redi-thotics provided on July 28, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99309-HE and G8427-HE billed for date of service 
April 28, 2023. 
 
You asked the Plan to pay for codes 99309-HE and G8427-HE. You say that you are having difficulty securing 
authorization for these services. The Plan denied your request. The Plan says these services were billed with an 
invalid modifier. The Plan must follow Medicare rules. Medicare rules say that the HE modifier is not payable 
for Medicare claims. You billed the services at issue with the HE modifier, which is not appropriate. Therefore, 
we decided that the Plan does not have to pay for codes 99309-HE and G8427-HE billed for date of service 
April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neuromonitoring billed with codes 95865, 
95868, and G0453 for date of service February 27, 2023. 
 
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that these services were 
ordered by an in-network provider.  In addition, these services were medically necessary. The Plan denied your 
request. The Plan says you did not bill these services with a coverable diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that intraoperative neuromonitoring services services 
are only covered when billed with a diagnosis that supports medical necessity. The full listing of coverable 
diagnoses is listed in this article. Any diagnoses not listed are considered not medically necessary.  
 
In this case, you billed the services in dispute with diagnosis code E21.5.  This diagnosis code is not listed as a 
coverable diagnosis for these services.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intraoperative neuromonitoring services have not been met. Therefore, we decided that the Plan 
does not have to pay for intraoperative neuromonitoring billed with codes 95865, 95868, and G0453 for date of 
service February 27, 2023.