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

 
We decided that the Plan does not have to pay for crowns - porcelain/ceramic (D2740), and core buildup, 
including any pins when required (D2950) provided on May 1, 2023. 
 
You asked the Plan to pay for the crowns and core buildup. You say that you had three core build ups to restore 
the teeth that were overfilled, worn down, and sensitive. You also say that the  three crowns you received were 
part of the restoration process and the plan states dental care for restorative purposes is covered in-network 
with a 50% coinsurance. The Plan denied your request. The Plan says procedure codes D2950 and D2740 are 
not listed as covered. The Plan also says Evidence of Coverage clearly states that the Plan does not cover 
services not listed in the schedule of benefits table. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crowns - 
porcelain/ceramic (D2740), and core buildup, including any pins when required (D2950) provided on May 1, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower commode chair.  
 
You asked the Plan to pre-approve a shower commode chair. You say that the enrollee has a secondary 
insurance policy that requires a written denial. 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 commode chair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
 
  The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services provided by an out-of-
network provider on March 30, 2022. 
 
You asked the Plan to pay for the emergency department services. You say that you originally billed the wrong 
insurance, and you submitted the claim when you received the proper insurance. The Plan denied your request. 
The Plan says the claim was filed 12 months after the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
  The record shows that a claim for the emergency department services was not filed until April 22, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the emergency department services provided by an 
out-of-network provider on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for doctor 
appointments. The Plan denied your request. The Plan says your request exceeds the benefit limit for the 
transportation program. 
 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 a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 8 
additional routine trips for doctors appointments. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve 8 additional routine transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81003 billed for date of service February 24, 
2023. 
 
You asked the Plan to pay for procedure code 81003. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81003 is bundled into 
payment for code G0483. 
 
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 81003 
is a column II code to column I code G0483. 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 81003 billed for date of service February 24, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220/D0230), periodontal maintenance 
(D4910), and a topical application of fluoride varnish (D1206), provided on April 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not receive a deep cleaning. The Plan 
denied your request. The Plan says the denied services are not covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral 
imaging (D0220/D0230), periodontal maintenance (D4910), and a topical application of fluoride varnish 
(D1206), provided on April 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport services provided on February 6, 
2023. 
 
You asked the Plan to pay for the ambulance transport services. You say that the services were medically 
necessary, and the enrollee was unable to ambulate independently. The Plan denied your request. The Plan says 
the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the ambulance transport services provided on 
February 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the intravenous (IV) therapy provided on 
May 23, 2023. 
 
You asked the Plan to waive the coinsurance for the IV therapy. You say that you were not informed that the 
medication was not 100% covered and you are not responsible for the charge. 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 20% 
coinsurance for Medicare-covered IV infusion therapy. The total allowed amount for the IV therapy was 
$203.10 with a coinsurance of $40.62 ($203.10 allowed x 20% coinsurance). 
 
  You have been asked to pay a 20% coinsurance for the IV therapy. This item/service falls within the outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the intravenous (IV) 
therapy provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (J2260, A4222, A4221) provided on 
August 21, 2022 to August 28, 2022. 
 
You asked the Plan to pay for the infusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery which support medical necessity for the supplies provided 
in this case. Supply codes A4222 & A4221 are not supported by an itemized delivery receipt. The number of 
units billed for code J2260 is not supported. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
infusion services (J2260, A4222, A4221) provided on August 21, 2022 to August 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, 
and 87798 provided on May 15, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, and 87798. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plans denial rationale is that each code billed is included in itself. We have 
confirmed that code 87481 is not a column II code to column I code 87481. We have confirmed that code 
87491 is not a column II code to column I code 87491. We have confirmed that code 87563 is not a column II 
code to column I code 87563. We have confirmed that code 87640 is not a column II code to column I code 
87640. We have confirmed that code 87653 is not a column II code to column I code 87653. We have 
confirmed that code 87798 is not a column II code to column I code 87798. We have confirmed that code 
87641 is not a column II code to column I code 87641. We have confirmed that code 87500 is not a column II 
code to column I code 87500. 
 
The Plan provided no other rationale for their denial of payment for these codes, therefore, we must find in 
your favor. Therefore, we decided that the Plan has to pay for procedure codes 87481, 87491, 87500, 87563, 
87640, 87641, 87653, and 87798 provided on May 15, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a dental crown (D2740) for tooth #18 
provided on June 14, 2023. 
 
You asked the Plan to waive the coinsurance for D2740. You say that you disagree with this coinsurance. 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 50% 
coinsurance for comprehensive dental services.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for D2740. The total allowed amount is 
$451.03. The total amount you are being asked to pay is $225.51 ($451.03 x 50% = $225.51). This item/service 
falls within the comprehensive dental services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a dental crown (D2740) for tooth #18 provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and G0108 provided on 
March 27, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and G0108. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and G0108 
provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on December 7, 
2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids provided in this 
case are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though these items may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
purchased on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740), and amalgam - two 
surfaces, primary or permanent (D2150) provided on January 5, 2023. 
 
You asked the Plan to pay for the crown and filling. You say that you do not understand why the crown and 
fillings are not covered under your dental plan. You also say that your husband's plan offered more coverage. 
The Plan denied your request. The Plan says crown and fillings are not a benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested  services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown - 
porcelain/ceramic (D2740), and amalgam - two surfaces, primary or permanent (D2150) provided on January 
5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on May 18, 2023. 
 
You asked the Plan to pay for D7210. You say that you believe this should be covered. The Plan denied your 
request. The Plan says dental extractions are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction (D7210) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 You asked the Plan to pre-approve the additional trips. You say that you have problems with your legs and you 
need this transportation urgently. You also say that you need to have a magnetic resonance imaging (MRI) and 
to attend appointments that you cannot drive to because you have no trips left. The Plan denied your request. 
The Plan says additional trips in excess of thirty-two (32) one-way trips are non-covered by the plan. 
 
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 a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional routine transportation trips for your appointments. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve additional routine transportation trips (A0100).  
 
Your complaint about the service representative not well oriented is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression wrap (A6545). 
 
You asked the Plan to pre-approve a compression wrap. 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 a gradient compression wrap is only covered when it 
is used as a primary or secondary dressing over wounds that meet the statutory requirements for a qualifying 
wound (surgically created or modified, or debrided). 
 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 a compression wrap. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the provided documentation did 
not reveal any skin breakdown, wounds, or other condition indicated for a gradient compression wrap under the 
LCD criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a compression wrap have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a compression wrap (A6545).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administrable medications. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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-administrable medications.   
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF as medically necessary care 
can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on June 06, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided support these services. 
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 skilled nursing facility 
provided on June 06, 2023.