Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided by an out-of-network 
provider from November 23, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the home health services. You say that you did not realize the claim was suppose 
to be billed as a Medicare claim. The Plan denied your request. The Plan says the claim was submitted after 1 
year from the dates of service. 
 
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 the home health services was not filed until June 14, 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 the home health services provided by an out-of-network provider 
from November 23, 2021, to November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on July 7, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that that while in the emergency room the 
doctors refused to give you treatment if you took medications on your own. The Plan denied your request. The 
Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 July 7, 2023.  
 
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on June 8, 2023. 
 
You asked the Plan to pay for D2740. You say that you believe that this should be overturned and paid. The 
Plan denied your request. The Plan says a crown is not a covered dental 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 pay for a crown 
(D2740) provided on June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D7951 and D6010). 
 
You asked the Plan to pre-approve the dental services (D7951 and D6010). You say that you need the service 
because your tooth is cracked and painful. The Plan denied your request. The Plan says the services requested 
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 pre-approve the 
dental services (D7951 and D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on May 22,2023. 
 
You asked the Plan to pay for the office visit. You say that you have been hurting with sciatic pain for several 
weeks and your physician was not able to see you because they had been booked up. The Plan denied your 
request. The Plan says that the only covered chiropractic service is manual manipulation of the spine. 
 
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 an office visit provided by a chiropractor on May 22,2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided by an out-of-network 
provider from December 16, 2021, to January 12, 2022. 
 
You asked the Plan to pay for the home health services. You say that due to a system issue the claim did not 
show up for billing on time. The Plan denied your request. The Plan says the claim was filed after 1 year from 
the dates of service. 
 
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 the home health services was not filed until June 14, 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 the home health services provided by an out-of-network provider 
from December 16, 2021, to January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3. The Plan denied your request. The Plan says the 
enrollee does not meet medical necessity criteria for the CGM. 
 
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 the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Libre 3 have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 3.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on June 5, 
2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that that you were not feeling 
well, and someone called the ambulance when you fell. The Plan denied your request. The Plan says they cover 
ambulance transportation only when you are transported by an ambulance. 
 
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 June 5, 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 services without transport received 
on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D2740, D0350, and D0220). 
 
You asked the Plan to pre-approve the dental services (D2740, D0350, and D0220). You say that you would 
like to request reconsideration of the denied dental services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested 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 pre-approve the 
dental services (D2740, D0350, and D0220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this service has never been provided to you 
before. 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, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00400) provided on May 19, 2023. 
 
You asked the Plan to pay for procedure code 00400. 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 separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one general anesthesia code is 
submitted on the same date of service by the same provider without a modifier to distinguish it as a separate 
surgical session or encounter, it will be denied. 
 
We looked at the file and Medicare rules. The same provider billed code 00731 for the same date of service, 
which was already paid. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services (00400) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), surgical access to an 
implant body (D6011) and implant supported crown (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial.  The Plan 
denied your request. The Plan says these services are not covered benefits 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 
endosteal implant (D6010), surgical access to an implant body (D6011) and implant supported crown (D6065).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534, 
A6533, A6535. 
 
You asked the Plan to pre-approve the compression stockings. he Plan denied your request. The Plan says this 
is not a covered service. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534, 
A6533, A6535 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534, A6533, A6535.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on August 2, 
2022.  
 
You asked the Plan to pay for ambulance services without transport. You say that you were not the one that 
called the ambulance, and you were able to drive yourself to the doctors. The Plan denied your request. The 
Plan says without transport there are no payable charges. 
 
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 August 2, 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 ambulance services without transport received on 
August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided on July 7, 2023. 
 
You asked the Plan to pay for D2391. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the denied 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 pay for a resin-
based composite (D2391) provided on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6545 that 
were issued on July 17, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the charges for outpatient supplies 
are excluded from coverage under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
A6545 that were issued on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
June 1, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a complete upper denture (D5110) and a 
partial lower denture (D5226) provided on March 2, 2023. 
 You asked the Plan to waive the coinsurance for the dental services. You say that you would like the Plan to 
pay for the dentures and you told the provider you did not want the new dentures they made. 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 40% 
coinsurance for comprehensive dental services: prosthodontics, other oral/maxillofacial surgery, and other 
services. The total allowed amount for the complete upper denture (D5110) was $780.68 with a coinsurance 
amount of $312.27 ($780.68 allowed x 40% coinsurance). The total allowed amount for the partial lower 
denture (D5226) was $771.65 with a coinsurance amount of $308.66 ($771.65 allowed x 40% coinsurance). 
 
You have been asked to pay a 40% coinsurance for the dental services. This item/service falls within the dental 
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 coinsurance for a complete upper denture 
(D5110) and a partial lower denture (D5226) provided on March 2, 2023.  
 
Your complaint about not wanting the dentures 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on May 19, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the Plan denied the item with the 
incorrect liability. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on May 19, 2023.  
 
Your complaint about the assessed liability issue is a processing dispute which must be resolved by the Plan it 
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 pre-approve incomplete endodontic therapy and treatment of root 
canal obstruction for tooth #31 (D3332, D3331). 
 
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 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 pre-approve 
incomplete endodontic therapy and treatment of root canal obstruction for tooth #31 (D3332, D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye examination provided on April 12, 
2023. 
 
You asked the Plan to waive the copayment for the copayment. You say that this is supposed to be an annual 
eye exam.  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 $10 
copayment for the diagnosis and treatment of diseases and injuries of the eye.  
 
You have been asked to pay $10 copayment for the office visit. This item/service falls within the vision care 
benefit category. The record shows you were seen due to a decrease in vision, which makes the eye 
examination medical in nature. 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 eye examination 
provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on May 26, 
2023. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that the claim on the bill states that 
you did a telehealth visit and you have never done this. 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 $15 
copayment for physician/practitioner services, including doctor's office visits.  
 
 You have been asked to pay a $15 copayment for the telehealth visit. This service falls within the 
physician/practitioner services, including doctor's office visits. 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 telehealth visit provided on May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0365) provided on June 14, 2022. 
 
You asked the Plan to pay for D0365. You say that this image was taken over a year ago and the dental office 
still has not moved forward with treatment. The Plan denied your request. The Plan says the denied 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 pay for a cone 
beam CT capture (D0365) provided on June 14, 2022.