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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on December 27, 2021. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the claim denied due to 
filing guidelines. You also say that since the payment was made the charges were updated changing the billed 
amount. The Plan denied your request. The Plan says the claim was untimely, and the submission did not meet 
the exception criteria guidelines. 
 
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 ambulance service and ground mileage was not filed until March 28, 
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 ambulance service, basic life support, 
emergency transport and ground mileage provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mirrors for a power wheelchair (K0108). 
 
You asked the Plan to pre-approve the mirrors. You say that these features are medically necessary. The Plan 
denied your request. The Plan says the reqeuested feature is not primarily medical in nature and is for use 
outside the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve mirrors for a power wheelchair (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial lower denture (D5214) provided on April 13, 2023. 
 
You asked the Plan to pay for the dental service. You say that you lost your previous denture, and you would 
like the Plan to reconsider and pay for the new denture. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a partial lower denture (D5214) on November 30, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of November 30, 2022. Therefore, we decided 
that the Plan does not have to pay for a partial lower denture (D5214) provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) and a retainer crown (D6740) for tooth #10 
and #11 provided on May 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed the bridge replaced and it should be 
covered under your crown benefit. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the pontic and the retainer crown 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 pontic 
(D6245) and a retainer crown (D6740) for tooth #10 and #11 provided on May 4, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) and the infrared therapy (99199) 
rendered by the out-of-network (OON) provider on March 1, 2023. 
 
You asked the Plan to pay for this item/service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was rendered by an out-of-
network provider, without prior authorization.  
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.   
 
 
 
We found no exception that would require the Plan to pay for this item/service. Therefore, we decided that the 
Plan does not have to pay for the sales tax (S9999) and the infrared therapy (99199) rendered by the out-of-
network (OON) provider on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic parenteral drug, single administration 
(D9610) provided on March 29, 2023. 
 
You asked the Plan to pre-approve the therapeutic parenteral drug, single administration. The Plan denied your 
request. The Plan says procedure D9610  drug injection is not covered under the 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
therapeutic parenteral drug, single administration (D9610) provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on  
May 11, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service June 4, 2019.  
  
 
 
 
Specifically, the Plans contract states that full mouth x-rays are covered every 5 years. You previously 
received a full mouth x-ray on June 4, 2019, less than five years prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for the service provided in this case. Therefore, we 
decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on May 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ground mileage, per statute mile (A0425) provided on 
January 23, 2023, and February 15, 2023. 
 
You asked the Plan to pay for the ground mileage. You say that you are appealing the denial for reimbursement 
for gas mileage. The Plan denied your request. The Plan says you did not make advance arrangements with the 
Plan's designated provider. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when 24.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for ground mileage, per statute mile (A0425) provided on January 23, 2023, and 
February 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 20, 2022. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
31, 2022. 
 
You asked the Plan to pay for the dental service. You say that you went to your regular dentist to have a 
cleaning and x-rays done. 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 comprehensive oral evaluation (D0150) on June 2, 2022, which was processed prior 
to the claim for May 31, 2022; therefore, your benefit for the requested item or service was exhausted on the 
date of service of June 2, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a cleaning 
(D1110), and the application of fluoride (D1206) provided by and out-of-network provider on April 18, 2023. 
 You asked the Plan to pay more for the dental services. You say that the providers office told you they were in-
network, and you should not have to pay for their mistake. 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. The proper cost share was applied to the covered dental services. Also, the 
application of fluoride 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. 
 
The total amount billed for the comprehensive oral evaluation (D0150) was $127 and the allowed amount was 
$85 leaving a difference of $42 ($127 billed - $85 allowed). The total coinsurance amount was $17 ($85 
allowed x 20% coinsurance). The total liability for the comprehensive oral evaluation (D0150) was $59 ($42 
difference + $17 coinsurance). The total amount billed for the cleaning (D1110) was $123 and the total allowed 
amount was $86 leaving a difference of $37 ($123 billed - $86 allowed). The total coinsurance amount was 
$17.20 ($86 allowed x 20% coinsurance). The total liability for the cleaning (D1110) was $54.20 ($37 
difference + $17.20 coinsurance). 
 
You have been asked to pay the 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. The application of fluoride is not covered under the Plans dental benefit. Therefore, we decided that 
the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a cleaning (D1110), and the 
application of fluoride (D1206) provided by and out-of-network provider on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a determination of refractive state 
provided on April 14, 2023. 
 
You asked the Plan to pay for an office visit and a determination of refractive state. You say that you are an in-
network provider. 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 and a 
determination of refractive state provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation (D9239 and D9243) provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not want to pay for the sedation. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
sedation 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
sedation (D9239 and D9243) provided on June 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on September 13, 
2022. 
 You asked the Plan to pay for the paramedic intercept service. You say that you do not feel you should be 
responsible for a service that you did not use. The Plan denied your request. The Plan says your coverage does 
not provide for this ambulance service. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
November 21, 2022, to December 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this Plan has coverage for durable 
Medical Equipment and these charges are medically necessary, therefore all charges should be paid in full. The 
Plan denied your request. The Plan says pneumatic compression device coded as E0675 to treat peripheral 
arterial disease is not eligible for reimbursement. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided November 21, 2022, to December 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography cerebral perfusion analysis (CTP) 
provided on November 22, 2022. 
 
You asked the Plan to pay for the CTP. You say that the records provided support medical necessity. 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 CT scans 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 pay for the CTP. Our reviewer says that the service 
was not medically necessary. Our physician reviewer found the rules state that CT perfusion will be reimbursed 
only if there is a large vessel occlusion amenable to intervention on standard CTA of the head and neck the 
same date. Review of the CTA reports showed no such large vessel occlusion. Therefore, reimbursement for 
the CTP is not indicated. 
 
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 CTP have not been met. Therefore, we decided that the Plan does not have 
to pay for a computed tomography cerebral perfusion analysis (CTP) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation provided on April 4, 2023. 
 
You asked the Plan to pay for the radiofrequency ablation. You say that you need this treatment because you 
have excruciating pain in your back. The Plan denied your request. The Plan says the radiofrequency ablation is 
not medically necessary.  
 
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 pay for the radiofrequency ablation. Our reviewer 
says that the radiofrequency ablation is not medically necessary. Our physician reviewer found the 
radiofrequency ablation is considered experimental and investigational because of the wide variation in 
efficacy reported in the literature. 
 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pay for the radiofrequency ablation provided on April 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity. 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says an MRI of the lower 
extremity is not medically necessary.  
 
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 an MRI. Our reviewer says that an MRI 
of the lower extremity is not medically necessary. Our physician reviewer found that there is an order for left 
hip x-rays dated July 17, 2023, with no results in the chart. The enrollee has been scheduled for their first 
physical therapy visit on July 31, 2023, however there is no notes concerning that visit or subsequent visits. 
Therefore, the medical necessity of the requested MRI of the left hip cannot be addressed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI of the lower extremity.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 2022. 
 You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on February 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 22, 2022. 
 You asked the Plan to pay for the ambulance services. You say that the services were not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on November 22, 2022.