Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for polarized cocoon sunglasses provided on June 8, 2023. 
 
You asked the Plan to reimburse for polarized cocoon sunglasses. You say that you call and spoke with a 
representative about the fit over polarized sunglasses. You also say that the representative told you that as long 
as they did not clip on and were polarized, they were allowed under your wellness wallet. The Plan denied your 
request. The Plan says this is a non-covered wellness wallet service. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym, fitness 
and wellness education benefits only The Plan rules say that the wellness wallet will reimburse up to $300 each 
year in total for fitness, naturopathic services, acupuncture, nutrition/dietary education, weight management 
programs, and face masks. Polarized cocoon sunglasses are not covered under the wellness wallet benefit. 
 
 
  The Plans rules for coverage of gym benefits have not been met because polarized cocoon sunglasses are not 
covered under the wellness wallet. Therefore, we decided that the Plan does not have to reimburse for polarized 
cocoon sunglasses provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist extension control cock-up, prefabricated provided on 
June 14, 2023. 
 
You asked the Plan to pay for wrist extension control cock-up, prefabricated. 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 wrist extension control 
cock-up, prefabricated provided on June 14, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency department visit (procedure 99284) performed on July 24, 
2023. 
 
You asked the Plan to pay for emergency department visit (procedure 99284). You say that procedure code 
99284 is appropriate based on the level of service required. The Plan denied your request. The Plan says that 
procedure code 99283 is more appropriate for the services rendered. 
 
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 99284 is emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for emergency department visit (procedure 99284). Our reviewer 
says that the services at issue in this case are supported by the medical records. Our reviewer found the Plan 
appears to be denying procedure code 99284 based on the pre 2023 definitions of the emergency department 
(ED) codes, stating that the history and physical are only expanded, not detailed. In 2023, the history and 
physical only have to be appropriate, which they are, and the medical decision making has to be moderate, 
which the Plan admits.  As such, the billing of CPT 99284 for July 24, 2023, is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency department visit (procedure 99284) have been met. Therefore, we 
decided that the Plan has to pay for emergency department visit (procedure 99284) performed on July 24, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on August 6, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the drug was prescribed to you in the 
emergency room. 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 August 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 05, 2023. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial and would like for the 
plan to reconsider payment. 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 July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the assessment and treatment for pain 
management provided on April 3, 2023. 
 
You asked the Plan to waive the copayment for the assessment and treatment the pain management. You say 
that you are on a limited income, you cannot afford to pay the billed amount. 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 $25 
copayment for pain management assessment and a $75 copayment per visit for pain management treatment.  
 
  You have been asked to pay a total of $100 for the assessment and treatment for pain management. You were 
billed a copayment of $25/assessment + $75/treatment = $100 total copayment. 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 waive the copayment for the assessment and treatment for pain management provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,500 annual maximum 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 $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on January 24, 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 August 4, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you went to the dentist because of a toothache, 
and you received a bill. 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 March 20, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 20, 2023. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the requested shower chair is medically 
necessary. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for porcelain/ceramic pontic (D6245), core buildup 
(D2950), and porcelain/ceramic crown (D6740) provided on May 25, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing. 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 this date of service. 
Therefore, we decided that the Plan does not have to pay more for porcelain/ceramic pontic (D6245), core 
buildup (D2950), and porcelain/ceramic crown (D6740) provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified removable prosthodontic procedure (D5899) 
provided on March 7, 2023. 
 
You asked the Plan to pay for unspecified removable prosthodontic procedure. 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 
unspecified removable prosthodontic procedure (D5899) provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bitewings - four radiographic images (D0274), 
periodic oral evaluation - established patient (D0120), and periodontal maintenance (D4910) provided on April 
18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reconsideration and 
reimbursement. 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 the bitewings - four radiographic images 
(D0274), periodic oral evaluation - established patient (D0120), and periodontal maintenance (D4910) 
provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97602 billed for date of service June 7, 2023. 
 You asked the Plan to pay for procedure code 97602. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says procedure code 97602 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97602 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97602 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97602 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97602 billed for date of service June 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on July 26, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you were in pain and had to go to the 
emergency room. 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 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services provided on May 
16, 2023. 
 
You asked the Plan to pay for the transitional care management services. 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 the transitional care 
management services provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 24, 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 July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an orthopantogram provided on September 
7, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit and an orthopantogram. You say that the doctor was listed as an 
in-network provider on the Plan's website. The Plan denied your request. The Plan says the services were 
received from an OON provider and there are multiple in-network providers available in your service area. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and an orthopantogram provided on 
September 7, 2023, by an out-of-network (OON) provider.
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 June 12, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had 
fallen days before and due to you having a migraine and vomiting you called the nursing line who then 
instructed you to call 911. You also say that when the medics arrived all your vitals were fine and you were 
tested to make sure you did not have a stroke. 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 June 12, 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 June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210), comprehensive oral evaluation - new or established patient (D0150), and full mouth debridement to 
enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit (D4355) provided on July 
31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel that the services are within the 
parameters of your insurance coverage. 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 intraoral  comprehensive series of radiographic images (D0210), comprehensive oral evaluation 
- new or established patient (D0150), and full mouth debridement to enable a comprehensive periodontal 
evaluation and diagnosis on a subsequent visit (D4355) provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided on August 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were in excruciating pain and the dentist 
needed to see what was going on. You also say that after reviewing the current x-ray, your tooth was 
immediately extracted. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service July 27, 2023. Therefore, we 
decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on July 12, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over 
the counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on July 12, 2023.