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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 7, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when the 
emergency medical technicians came into the house, they checked you and the atrial fibrillation had reverted. 
You also say that you didn't want to go to the hospital as your husband had passed there. 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 November 7, 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 the ambulance response and treatment with no 
transport provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion services provided on November 15, 2022, to 
November 16, 2022. 
 
You asked the Plan to pay for the infusion services. You say that other claims for these services have been 
covered. 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 infusion services 
provided on November 15, 2022, to November 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on June 16, 2021. 
 
You asked the Plan to pay for a home health visit. You say that medical records verify medical necessity. The 
Plan denied your request. The Plan says this claim was not filed timely. 
 
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 a home health visit was not filed until January 10, 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 a home health visit provided on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
12, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 24, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. 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 subsequent nursing 
facility care provided on June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2393) provided on June 7, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered 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 (D2393) provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 27, 2022, to December 12, 
2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 June 27, 2022, to December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 29, 
2022. 
 
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 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 June 2, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on 
October 24, 2022. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that your provider said this 
would be covered. 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the aflibercept injection. This item/service falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $361.20 ($1,806 allowed amount x 20% coinsurance = $361.20). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the aflibercept injection 
provided on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 6, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 5, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of implant body (D6010), a bone graft 
(D6104), an extraction (D7210), deep sedation (D9222 and D9223), and therapeutic drugs (D9612) for tooth 
#7, #8, and #9 provided on December 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary to get the dental 
services done due to an accident. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because they are not covered by the Plan or by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a surgical placement of implant 
body (D6010), a bone graft (D6104), an extraction (D7210), deep sedation (D9222 and D9223), and 
therapeutic drugs (D9612) for tooth #7, #8, and #9 provided on December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) and intraoral - occlusal radiographic image (D0240) provided on January 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay the billed charges for 
the services you received. 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. This benefit includes the 
requested intraoral - periapical each additional radiographic image (D0230) and intraoral - occlusal 
radiographic image (D0240) but is limited to one procedure code per calendar year. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered intraoral - periapical first radiographic image (D0220) on January 13, 2023. 
Therefore, these benefits were exhausted as of January 13, 2023. Although these are three different services, 
they fall within the same category in your Evidence of Coverage and are subject to the same frequency 
limitations. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional 
radiographic image (D0230) and intraoral - occlusal radiographic image (D0240) provided on January 13, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and intraoral 
- comprehensive series of radiographic images (D0210) provided on December 20, 2022. 
 
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 a comprehensive oral evaluation (D0150) 
and intraoral - comprehensive series of radiographic images (D0210) provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) x2 provided on January 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you think the services should be covered, 
because you have not used your benefits until this year. 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. This benefit includes the 
requested intraoral - periapical each additional radiographic image (D0230) but is limited to one procedure 
code per calendar year. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered periapical first radiographic image (D0220) on January 16, 2023. Although these 
are two different services, they fall within the same category in your Evidence of Coverage and are subject to 
the same frequency limitations. Therefore, these benefits were exhausted on January 16, 2023. Therefore, we 
decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (D0230) 
x2 provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation (D0170) provided on December 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that a simple tooth extraction should be covered 
under the dental plan. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the re-evaluation is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a re-
evaluation (D0170) provided on December 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care services provided on July 
20, 2022, to December 28, 2022. 
 
You asked the Plan to waive the copayment for the wound care services. You say that the services should not 
be billed as surgery. 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 $100 
copayment for outpatient hospital surgery services. 
 
You have been asked to pay a $100 copayment for the wound care services. This item/service falls within the 
outpatient hospital surgery 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. The total you owe is $1,900 ($100 copayment x 19 visits = $1,900). Therefore, 
we decided that the Plan does not have to waive the copayment for the wound care services provided on July 
20, 2022, to December 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each chemotherapy drug provided on 
March 07, 2022. 
 
You asked the Plan to waive the coinsurance for each chemotherapy drug. You say that you just received a bill 
for services rendered 9 months ago. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for each chemotherapy drug. This item/service falls within the 
Medicare Part B prescription drugs 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 
each chemotherapy drug provided on March 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on December 19, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told your bill was paid in full, but later 
found out services were denied. You say you should not have to pay the billed services. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) is not covered 
under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9310 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on December 19, 2022.
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 August 2, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you denied 
the transport because you did not feel the need to go to the hospital. You also say that you did not know that by 
refusing transport you would be responsible for the bill. 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 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 the ambulance response and treatment with no 
transport provided on August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the blood collection services from an 
implanted device provided from May 5, 2022, to October 5, 2022. 
 
You asked the Plan to waive the copayment for the blood collection services. You say that you think that the 
copayment should be lower. 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 $200 
copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility. 
 
 You have been asked to pay a $610.15 copayment for the blood collection services because the allowed amount 
for each service is less than the $200 copayment. These items/services fall within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 blood collection services from an implanted device 
provided from May 5, 2022, to October 5, 2022.