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

 
We decided that the Plan does not have to pay for the hospital services provided from January 5, 2023, to 
January 11, 2023. 
 You asked the Plan to pay for the hospital services. You say that the services are a covered benefit. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 5, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital services 
provided from January 5, 2023, to January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter items purchased on March 21, 2023. 
 
You asked the Plan to reimburse for over-the-counter items purchased. You say that you did not realize you 
had to submit the receipts within 120 days of service. The Plan denied your request. The Plan says claims must 
be submitted for reimbursement within 120 days of the purchase/service date. 
 
The rules say that Medicare does not pay for OTC items and over-the-counter items is an OTC item. The Plan 
rules say that claims must be submitted for reimbursement within 120 days of the purchase/service date. The 
record shows the items were purchased on March 21, 2023. One hundred twenty days from March 21, 2023, 
was July 19, 2023. The record shows the claim was received on August 25, 2023. Therefore, we decided that 
the Plan does not have to reimburse for over-the-counter items purchased on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740), and bitewings - 
two radiographic images (D0272) provided on June 22, 2023, and August 3, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reconsideration and to 
please accept your amended receipt for reimbursement. The Plan denied your request. The Plan says your 
benefit for the requested item or service $2,000 dollar limit was met 
 
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 services was exhausted on date of service June 22, 2023. Therefore, we 
decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740), and bitewings - 
two radiographic images (D0272) provided on June 22, 2023, and August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for standard frames (V2020), progressive lenses (V2781), 
lenses (V2783) and anti-reflective coating (V2750) provided on July 24, 2023.  
You asked the Plan to reimburse for standard frames (V2020), progressive lenses (V2781), lenses (V2783) and 
anti-reflective coating (V2750). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says this benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one pair of standard lenses and frames 
every two years. The record shows this benefit was exhausted on May 25, 2022. Based on this information, we 
decided that the Plan's rules for coverage of standard frames (V2020), progressive lenses (V2781), lenses 
(V2783) and anti-reflective coating (V2750) have not been met. Therefore, we decided that the Plan does not 
have to reimburse for standard frames (V2020), progressive lenses (V2781), lenses (V2783) and anti-reflective 
coating (V2750) provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist appointment was a routine annual 
exam, cleaning, and x-rays. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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) and the intraoral complete series of 
radiographic images (D0210) on August 18, 2021; therefore, your benefit for the requested items or services 
was exhausted on the date of service of August 18, 2021. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and the panoramic radiographic image (D0330) provided 
on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided on August 15, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that your previous dentist retired so 
you had to look for another dentist. You also say that your new dentist had to do an oral evaluation and take x-
rays as you were a new patient. The Plan denied your request. The Plan says your benefit for the requested 
comprehensive oral evaluation has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service January 9, 2023. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient 
(D0150) provided on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning, consultation, and veneer restoration services 
(D2910, D1110, D9310) provided on October 25, 2022, to December 8, 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 the dental services were received from an out-of-
network and out-of-area 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 cleaning, consultation, and veneer restoration services (D2910, D1110, D9310) provided on 
October 25, 2022, to December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) provided on 
January 11, 2022, and January 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were staying out of state for the winter and 
you could not file for reimbursement until you got home. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the claim was filed 365 after the dates 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 dental services was not filed until July 21, 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 unspecified adjunctive procedure (D9999) provided on January 11, 2022, 
and January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation (D0180) provided on 
July 20, 2023. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
comprehensive periodontal evaluation (D0180) provided on July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), and intraoral - complete series of radiographic images (D0210) provided on August 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting the plan to pay for the 
additional oral exam and x-rays for the new dentist needing their own x-rays. The Plan denied your request. 
The Plan says your benefit for the requested services 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 services was exhausted on date of service April 3, 2023. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient 
(D0150), and intraoral - complete series of radiographic images (D0210) provided on August 17, 2023.  
 
Your complaint about the dental practice being dishonest 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
on August 23, 2023. 
 
You asked the Plan to pay for the bitewings. You say that when you saw the provider for a cleaning, they took 
radiographic images because it is their standard office procedure to have images that are no greater than 12 
months. You also say that since you are a 71 year old diabetic you felt the radiographs were justified as part of 
the cleaning procedure. The Plan denied your request. The Plan says your benefit for the requested bitewings 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service March 7, 2023. Therefore, we 
decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided on 
August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter items purchased on February 24, 
2023. 
 
You asked the Plan to reimburse for over-the-counter items. You say that you did not realize you had to submit 
the receipts within 120 days of service. The Plan denied your request. The Plan says claims must be submitted 
for reimbursement within 120 days of the purchase/service date. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter items is an OTC item. The Plan rules say that claims must be submitted for reimbursement within 120 
days of the purchase/service date. The record shows the items were purchased on February 24, 2023. One 
hundred twenty days from February 24, 2023, was June 24, 2023. The record shows the claim was received on 
August 24, 2023. Therefore, we decided that the Plan does not have to reimburse for over-the-counter items 
purchased on February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator purchased on July 3, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you believe the provider was in network. 
The Plan denied your request. The Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the oxygen 
concentrator purchased on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter items purchased on February 18, 
2023. 
 
You asked the Plan to reimburse for over-the-counter items. You say that you did not realize you had to submit 
the receipts within 120 days of service. The Plan denied your request. The Plan says claims must be submitted 
for reimbursement within 120 days of the purchase/service date. 
 
The rules say that Medicare does not pay for OTC items and over-the-counter items is an OTC item. The Plan 
rules say that claims must be submitted for reimbursement within 120 days of the purchase/service date. The 
record shows the items were purchased on February 18, 2023. One hundred twenty days from February 18, 
2023, was June 18, 2023. The record shows the claim was received on August 25, 2023. Therefore, we decided 
that the Plan does not have to reimburse for over-the-counter items purchased on February 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220), a crown (D2740), 
and core buildup (D2950) for tooth #2 provided on April 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that in the past you always submitted the claims at 
the end of the year, and you would like the Plan to partially cover the dental services. The Plan denied your 
request. The Plan says claim was received after 120 days from the date of service. 
 
Medicare generally does not cover supplemental benefits. 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 that a claim for the dental services was not filed until September 14, 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 the intraoral radiographic image (D0220), a crown (D2740), and core buildup 
(D2950) for tooth #2 provided on April 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on June 28, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says since there was no 
transport, ambulance charges are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 28, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided on August 24, 2023. 
 
You asked the Plan to pay for hearing aids (V5298). You say that you were not aware that you had to go to a 
particular location for your hearing aids. The Plan denied your request. The Plan says hearing aids ordered 
through providers other than the Plan hearing are not covered. 
 
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 the hearing aids are obtained through a Plan hearing network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5298) provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on November 30, 
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 the services denied correctly as they do not fall 
within your 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 a dental 
consultation (D9310) provided on November 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services received on July 28, 2023. 
 
You asked the Plan to pay for the paramedic intercept services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services do not meet the requirements for payment. 
 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 received on July 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport services 
received on June 10, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary due to your low blood sugar. The Plan denied your request. The Plan 
says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 10, 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 response and treatment without 
transport services received on June 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on August 4, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you were unaware that if you didn't go on the ambulance the services would not be covered. The Plan denied 
your request. The Plan says without transport there are no payable services. 
 
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 4, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on August 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (99284) provided on January 
16, 2022. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the claim was filed 
untimely. 
 
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 ER visit was not filed until July 18, 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 an emergency room (ER) visit (99284) provided on January 16, 2022.