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

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 test kits provided on 
June 27, 2023. 
 You asked the Plan to pay for over-the-counter (OTC) COVID-19 test kits. You say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over-the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The rules say that Medicare does not pay for OTC items and over-the-counter COVID-19 test kits is an OTC 
item. Although the Plan offers coverage for OTC items, over-the-counter COVID-19 test kits are excluded 
from this benefit. Therefore, we decided that the Plan does not have to pay for over-the-counter (OTC) 
COVID-19 test kits provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on July 25, 2023. 
 
You asked the Plan to pay for the office visit. You say that this is a service that you have been using since 2019 
without any issues with the physician. You say that you needed the service due to a gym injury that you needed 
corrected. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on July 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services received on August 19, 
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 paramedic intercept is not a covered benefit. The Plan must follow Medicare rules. 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 under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic 
intercept services received on August 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on September 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe the Plan should pay more. 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.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for dental services provided by an out-of-
network provider on September 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services received on July 25, 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 no payment can be made as paramedic intercept is not 
covered. The Plan must follow Medicare rules. 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 under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services received on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of preimplant defect & clean implant (D6101), 
unspecified implant procedure (D6199), deep sedation/general anesthesia- first 15 minutes (D9222 and 
D9223), therapeutic parenteral drug, single administration (D9610), and bone graft (D6103) provided on July 
26, 2023. 
 
You asked the Plan to pay for these dental services. 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 debridement of preimplant defect & clean implant (D6101), unspecified implant procedure (D6199), deep 
sedation/general anesthesia- first 15 minutes (D9222 and D9223), therapeutic parenteral drug, single 
administration (D9610), and bone graft (D6103) provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on June 30, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over-
the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D6067) on May 15, 2023. 
 
You asked the Plan to pay for the dental service (D6067). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 15, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental service (D6067) on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D140) and to pay for the 
palliative treatment (D9110) provided by an out-of-network provider on May 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the provider did not mention you would 
be charged more than $25. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Also, the palliative treatment 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 limited oral evaluation (D0140) was $175 and the total allowed amount was $50 
leaving a difference of $125 ($175 billed - $50 allowed). 
 
You have been asked to pay 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 
palliative treatment is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not 
have to pay more for the limited oral evaluation (D140) and to pay for the palliative treatment (D9110) 
provided by an out-of-network provider on May 26, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J1642 and E0776 rendered on June 1, 2023, 
to June 7, 2023. 
 You asked the Plan to pay for the procedure codes J1642 and E0776. 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 July 1, 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 procedure codes J1642 and 
E0776 rendered on June 1, 2023, to June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and manual therapy techniques 
(97140) provided by a chiropractor on July 20, 2023, to, July 25, 2023. 
 
You asked the Plan to pay for the office visit (99203) and manual therapy techniques (97140). You say that you 
were under the impression that in some cases a reputable chiropractic doctor was covered by the Plan. The Plan 
denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) and manual therapy techniques (97140) provided by a 
chiropractor on July 20, 2023, to, July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composites (D2392) provided on May 31, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should pay for this. 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.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a resin-based composites (D2392) provided 
on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) and gingival irrigation with a medicinal 
agent (D4921) provided on August 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
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 D0274 was exhausted on date of service February 9, 2023. D4921 is not a covered 
dental benefit. Therefore, we decided that the Plan does not have to pay for bitewings (D0274) and gingival 
irrigation with a medicinal agent (D4921) provided on August 17, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on June 10, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on June 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 test kits provided on 
June 26, 2023. 
 You asked the Plan to pay for over-the-counter (OTC) COVID-19 test kits. You say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over-the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The rules say that Medicare does not pay for OTC items and over-the-counter COVID-19 test kits is an OTC 
item. Although the Plan offers coverage for OTC items, over-the-counter COVID-19 test kits are excluded 
from this benefit. Therefore, we decided that the Plan does not have to pay for over-the-counter (OTC) 
COVID-19 test kits provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on March 10, 2023. 
 
 
You asked the Plan to pay more for the dental services. You say that you needed this dental work. 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.  
 
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. 
 
You have been asked to pay 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 enrollee also reached their maximum dental allowance amount on March 10, 2023. Therefore, we decided that 
the Plan does not have to pay more for dental services provided on March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified periodontal service (D4999) provided on July 
18, 2023. 
 
You asked the Plan to pay for D4999. You say that you were never told that this procedure was not covered. 
The Plan denied your request. The Plan says the denied dental service is not a covered dental benefit. 
 
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. All of the other services provided have been approved and paid. 
Therefore, we decided that the Plan does not have to pay for an unspecified periodontal service (D4999) 
provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral imaging (D0350) provided on June 22, 2023. 
 
You asked the Plan to pay for D0350. You say that this dental work was medically necessary. The Plan denied 
your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 2D oral 
imaging (D0350) provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 10, 
2023. 
 
You asked the Plan to pay for the office visit. You say that you have had previous appointments with this 
specific physician, and they have not been denied. The Plan denied your request. The Plan says the only 
covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on August 10, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes 96413, J9299, 99214, 85025 for services 
received on July 11, 2023. 
 
You asked the Plan to pay for the procedure codes 96413, J9299, 99214, 85025. You say that you were not on 
hospice at the time the services were rendered. 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 July 6, 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 procedure codes 96413, 
J9299, 99214, 85025 for services received on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5261) provided on July 24, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5261). You say that you spoke with someone from the 
Plan, and you were told that you could use an out-of-network provider as long as you had a referral from your 
primary care physician (PCP). The Plan denied your request. The Plan says you did not have a referral on file. 
The Plan also says that you were advised by the Plan representative on May 23, 2023, that you must stay in-
network to utilize your copayment structure. The Plan also says that the hearing aids purchased are not 
included on the Plan hearing approved list. 
 
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 (V5261) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5261) provided on July 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on May 
28, 2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that the services were 
medically necessary, and you were told you did not have to go to the hospital. The Plan denied your request. 
The Plan says without transport there is not payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 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 services without transport received 
on May 28, 2023.