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

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on August 15, 2023. 
 
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 an 
endosteal implant (D6010) provided on August 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you attempted to bill this claim as soon as 
possible and were attempting to bill another payer who eventually denied the claim. The Plan denied your 
request. The Plan says the information provided does not support an extension for the timely filing limit. 
 
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 services was not filed until June 15, 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, non-emergency transport, 
and ground mileage provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 13, 
2022, through August 15, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
  
 
 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these services have been met.  
Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
August 13, 2022, through August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autogenous connective tissue graft procedure (D4273). 
 
You asked the Plan to pre-approve autogenous connective tissue graft procedure. You say that you would at 
least like a percentage of the procedure paid. 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 pre-approve 
autogenous connective tissue graft procedure (D4273).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) provided on June 30, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781). You say that both you and the eye center were not 
aware that progressive lenses were not covered. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say that covered services include one pair of 
eyeglasses after each cataract surgery that includes insertion of an intraocular lens. Eyewear upgrades or 
enhancements that are not medically necessary or covered by Medicare are not covered. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses (V2781) have not been met. 
Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) provided on June 30, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials to aid in soft and osseous tissue 
regeneration and deep sedation/general anesthesia (D9223, D4265, D9222) provided on March 21, 2023. 
 
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 biologic 
materials to aid in soft and osseous tissue regeneration and deep sedation/general anesthesia (D9223, D4265, 
D9222) provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that your physician determined that the custom 
orthotics are medically necessary, and you have worn them for over 20 years. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified oral surgery (D7999). 
 
You asked the Plan to pre-approve unspecified oral surgery. You say that this is medically necessary. 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 pre-approve 
unspecified oral surgery (D7999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471). 
 
You asked the Plan to pre-approve removal of lateral exostosis. You say that this is medically necessary. 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 pre-approve 
removal of lateral exostosis (D7471).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 23, 
2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the enrollee had two trips 
in one day and the other trip has been paid. You also say to review both the submitted run reports and reprocess 
claim. 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).  The enrollees contract with the Plan clearly says that enrollees must pay a $290 copayment for per each non-
emergency ground ambulance service regardless of the number of trips. 
 
You have been asked to pay a $268.34 copayment for the ambulance services which is lower than the $290 
copayment. This service falls within the ambulance services benefit category. This means you have been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for ambulance services provided on March 23, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 76857, 76770, and 76856 provided from October 22, 
2022, to October 24, 2022. 
 
You asked the Plan to pay for procedure codes 76857, 76770, and 76856. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to 
make a determination within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the services billed on October 22, 2022, and October 24, 2022, based on Medicare criteria. 
Therefore, we decided that the Plan has to pay for procedure codes 76857, 76770, and 76856 provided from 
October 22, 2022, to October 24, 2022.  
 
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 pay for a cleaning (D1110) provided by an out-of-network provider 
on July 13, 2023. 
  You asked the Plan to pay for the dental service. You say that the implant has a lifetime warranty, and the Plan 
should cover the dental services regardless of if the provider is not in-network. The Plan denied your request. 
The Plan says the dental service was 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 item or service is 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 (D1110) provided by an out-of-network provider on July 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LDCT scan. 
 
You asked the Plan to pre-approve an LDCT scan. You say that the enrollee meets the criteria for the requested 
scan to be approved. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for the requested scan to be approved. 
 
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 pre-approve a low dose CT scan. Our reviewer says 
that the requested scan is not medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee has stopped smoking in 1999 which is more than 15 years ago and is not a current 
smoker. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 low dose CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a LDCT scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for C4-7 anterior cervical 
discectomy and fusion. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow 
aspirate in the setting of spinal fusion surgery have not been demonstrated. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found evidence is insufficient to support the use of bone marrow aspirate combined with 
synthetic or allograft materials as a substitute or supplementary graft to autologous bone graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for C4-7 anterior cervical discectomy and fusion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided July 25, 2023, coded as 
87798-15 x13, 87481-59 x5. 
 
You asked the Plan to pay for the laboratory testing. You say that please review the attached records. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided July 
25, 2023, coded as 87798-15 x13, 87481-59 x5.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques, requiring use of operating 
microscope (69990). 
 
You asked the Plan to pre-approve microsurgical techniques. You say that the requested surgery is medically 
necessary due to significant functional impairment greater than 10 months. The enrollee is experiencing 
unremitting pain, significant functional impairment that continues despite disability that has proved refractory 
to at least 6 consecutive months of structured physician supervised conservative medical management. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
service. 
 
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 microsurgical techniques. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic back pain, spinal stenosis, degenerative disc disease, with 
foraminal stenosis. A request for spinal fusion surgery was approved. However, a request for microsurgical 
techniques, requiring use of operating microscope (69990) as an unbundled procedure was not supported in the 
provided documentation as it is already bundled into the current procedural terminology (CPT) codes already 
approved for the fusion surgery. Therefore, the CPT code 69990 will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microsurgical techniques have not been met. Therefore, we decided that the 
Plan does not have to pre-approve microsurgical techniques, requiring use of operating microscope (69990).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the expandable controller with harness upgrade and electronic 
connection. We decided that the Plan does not have to pre-approve the foot plate brackets and calf pads. 
 
You asked the Plan to pre-approve an expandable controller with harness upgrade and electronic connection, 
foot plate brackets, and calf pads for a power wheelchair (PWC). You say that you disagree with the denial. 
The Plan says that the services are not covered. 
 
We decided that the Plan has to pre-approve the expandable controller with harness upgrade and 
electronic connection. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the expandable controller with harness and electronic connection are medically necessary. Our physician 
reviewer found that the enrollee is non-ambulatory and requires a PWC for mobility and performing daily 
activities. There is a history of skin breakdown. The complexity of the enrollee's seating and positioning needs 
necessitates a more complex group 3 power wheelchair base. The expandable controller with harness and 
electronic connection are necessary to operate the group 3 power wheelchair base and the three power options 
via a joystick. These components are required to operate 3 or more power options on a group 3 power 
wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve the expandable controller with harness upgrade and electronic connection. 
 
We also decided that the Plan does not have to pre-approve the foot plate brackets and calf pads. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the requested foot plate brackets and calf pads are included in the already approved Group 3 
PWC. Therefore, we decided that the Plan does not have to pre-approve the foot plate brackets and calf pads. 
 
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 pay for an eye refraction (92015) provided on December 5, 2022.  
You asked the Plan to pay for an eye refraction (92015). You say that you told the Plan representative that you 
would always use the doctors you have. You also say that the Plan representative told you no problem. The 
Plan denied your request. The Plan says not a covered expense under the Plan. 
 
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 these services when the eye refraction is part of a routine eye examination.. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only covered when part of 
a routine eye examination. Based on this information, we decided that the Plan's rules for coverage of an eye 
refraction (92015) have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on December 5, 2022.  
 
Your complaint about your disappointment with the potentially poor service received from the Plan 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.