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

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on February 
20, 2022. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that it was an emergency 
situation and you required treatment. The Plan denied your request. The Plan says the Medicare ambulance 
benefit is a transportation benefit and without a transport there is no payable service. 
 
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 February 20, 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 treatment without transport provided 
on February 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
March 9, 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 items at issue 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 (V5298) purchased on March 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of an upper 
extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that you are having shoulder issues and need it taken care 
of. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found no red flags were noted on the physical exam 
of the right shoulder. X-rays showed mild degenerative changes. No contraindication to a 6-week trial of 
physical therapy is shown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of an upper extremity joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 26, 2023. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you had a medical emergency, and 
you were taken to the hospital. 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 $175 
copayment for a CT-Scan, MRI, MRA, PET, Nuclear Stress Testing and Other Diagnostic Radiological 
Services.  
 You have been asked to pay a $175 copayment for the CT scan. This item/service falls within 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 a computed tomography (CT) scan provided on March 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on April 20, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the services should be 
covered. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation 
benefit and without a transport there is no payable service. 
 
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 April 20, 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 ambulance treatment without transport provided 
on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), pulpal debridement, primary and permanent teeth 
(D3221), endodontic therapy, molar tooth (excluding final restoration) (D3330), prefabricated post and core in 
addition to crown (D2954), and crown - porcelain/ceramic (D2740) provided on December 31, 2022, to 
January 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you strongly feel that you should not be 
responsible for these claims because all the dental procedures were medically necessary. 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 a limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image 
(D0220), pulpal debridement, primary and permanent teeth (D3221), endodontic therapy, molar tooth 
(excluding final restoration) (D3330), prefabricated post and core in addition to crown (D2954), and crown - 
porcelain/ceramic (D2740) provided on December 31, 2022, to January 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2751) and core buildup (D2950) for tooth #30 
provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of the 120 days timely filing 
limit to submit for reimbursement. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the claim was received after 120 days from the date of 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, certain limitations apply. The record 
shows that the claim for the dental services was not filed until July 13, 2023. This means that more than 120 
days 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 crown (D2751) and core buildup (D2950) for tooth #30 provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953), and surgical removal of implant body (D6100) provided on February 14, 2023. 
 
You asked the Plan to pay for the bone replacement graft and surgical removal of implant body. You say that 
the services were necessary to repair a damaged implant. The Plan denied your request. The Plan says 
procedure codes D7963 and D6100 are not listed as covered benefits under your supplemental 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 pay for a bone 
replacement graft for ridge preservation - per site (D7953), and surgical removal of implant body (D6100) 
provided on February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of fracture bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on April 9, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you live on a fixed 
income and cannot afford the bill. The Plan denied your request. The Plan says the Medicare ambulance benefit 
is a transportation benefit and without a transport there is no payable service. 
 
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 April 9, 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 ambulance treatment without transport provided 
on April 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on 
November 30, 2022. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you had experienced a 
medical emergency and could not get to the car. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
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 30, 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 treatment without transport provided 
on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740 x 2) provided on February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider informed you that these 
procedures would be covered, and your responsibility would only be for $156. 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 February 22, 2022. 
Therefore, we decided that the Plan does not have to pay for the crowns (D2740 x 2) provided on February 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of 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 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) provided on 
December 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that your handbook states that there is a 50% 
coinsurance for restorative services, and you would like to be reimbursed for half of the bill. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because the crown and core 
buildup 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 pay for a crown 
(D2740) and core buildup (D2950) provided on December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 and L3 kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve T10 and L3 kyphoplasty. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve T10 and L3 kyphoplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no trial of a back brace for fracture treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of T10 and L3 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T10 and L3 kyphoplasty (22513, 22515).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0150, D0210, D2950, and D2740) on 
December 8, 2022. 
 
You asked the Plan to pay for the dental services (D0150, D0210, D2950, and D2740). You say that you would 
like to request reconsideration of the denied claim and that the services requested are medically necessary. The 
Plan denied your request. The Plan says your benefit for the requested services (D0150 and D0210) has already 
been exhausted. The dental services (D2950 and D2740) 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, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service services (D0150 and 
D0210) June 4, 2021. Therefore, we decided that the Plan does not have to pay for the dental services (D0150, 
D0210, D2950, and D2740) on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral 
complete series of radiographic images (D0210) and a cleaning (D1110) provided by an out-of-network 
provider on June 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider was out-of-
network and they never informed you of that information. 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 a comprehensive oral evaluation (D0150), the intraoral complete series of radiographic images 
(D0210) and a cleaning (D1110) provided by an out-of-network provider on June 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occipital nerve radiofrequency ablation (RFA) 
procedure (64640). 
 
You asked the Plan to pre-approve occipital nerve RFA procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve occipital nerve RFA procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found occipital nerve RFA is experimental for posterior neck pain and headaches. 
More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occipital nerve RFA procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve occipital nerve radiofrequency ablation (RFA) procedure (64640).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning (D1110) provided by an out-of-network 
provider on April 14, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you have an acquaintance who is also with 
the Plan and has the same dentist, but they receive full compensation for an annual cleaning. 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. Also, the proper cost share was applied.  
 
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 total amount billed for the cleaning (D1110) was $110 and the total allowed was $37 leaving a difference 
of $73 ($110 billed - $37 allowed). The total amount for the coinsurance was $18.50 ($37 allowed x 50% 
coinsurance). Your total liability for the cleaning (D1110) was $91.50 ($73 difference + $18.50 coinsurance). 
 
You have been asked to pay a 50% coinsurance and 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 cleaning (D1110) 
provided by an out-of-network provider on April 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you believe the scan is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is no discussion of possible FTD in 
the records. The base requirements for coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.