Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prosthetic supplies (L2330 and L1940) 
provided on April 27, 2023. 
 
You asked the Plan to waive the coinsurance for prosthetic supplies (L2330 and L1940). You say that you 
should not have a 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 20% 
coinsurance for in-network Medicare-covered prosthetic devices, supplies related to prosthetic devices and 
orthotics. 
  You have been asked to pay a total of $129.32 for the prosthetic supplies (L2330 and L1940).  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
April 27, 2023 L2330 $273.82 20% $54.76 
April 27, 2023 L1940 $372.81 20% $74.56 
TOTAL:    $129.32 
 
These items fall within the prosthetic devices and related supplies 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 prosthetic supplies (L2330 and L1940) provided on April 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on March 10, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on February 22, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that you have severe plantar fasciitis, and you need the 
customer foot orthotics. 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 pay for foot orthotics provided on February 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee has been redirected to a local in-network neurologist for an initial 
evaluation. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on April 12, 2023. 
 
You asked the Plan to pay for the physician services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 find that CPT code 99223 is not supported in the medical record. Specifically, the records show the patient 
was under outpatient observation, however the service was billed with place of service 21 (inpatient). Based on 
this information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99223) provided on April 12, 
2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on January 18, 2023. 
 
You asked the Plan to pay for the ambulance transport services. You say that the claim should not have denied 
and asks the Plan to review the submitted medical records and process claim for payment.  The Plan denied 
your request. The Plan says that our policy covers non-emergency ambulance transportation when it is the only 
way to safely and adequately transport a member or if other means of transporting a member are unsafe due to 
a medical condition. This claim does not meet these requirements.  
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance transport services. Our 
reviewer says that the ambulance transport services were medically necessary. Our physician reviewer found 
the method of transport was medically necessary due to the enrollee's conditions. It was noted that the enrollee 
is unable to sit up in a wheelchair for duration of the transport due to his profound weakness. Alternative 
modes of transportation are unsafe and therefore contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance transport services have been met. Therefore, we decided that the 
Plan has to pay for ambulance service, basic life support, non-emergency transport, and ground mileage 
provided on January 18, 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 pay for periapical first film (D0220) and limited oral evaluation 
(D0140) provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 items or services were exhausted on date of service March 31, 2023. 
Therefore, we decided that the Plan does not have to pay for periapical first film (D0220) and limited oral evaluation (D0140) provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2023, to May 20, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2023, to May 20, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on April 4, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the services were 
medically necessary for the health and safety of the enrollee.  The Plan denied your request. The Plan says that 
our policy covers non-emergency ambulance transportation when it is the only way to safely and adequately 
transport a member or if other means of transporting a member are unsafe due to a medical condition. This 
claim does not meet these requirements. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service and ground mileage. 
Our reviewer says that the ambulance services were medically necessary. Our physician reviewer found the 
mode of transportation selected was medically necessary due to the enrollee's profound weakness. It was noted 
in the documentation that the enrollee is unable to sit up in a wheelchair for the duration of transport. The 
enrollee would also be unable to brace himself from a fall. Alternative mode of transportation is therefore 
contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance service and ground mileage have been met. Therefore, we 
decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and ground 
mileage provided on April 4, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care and nail debridement provided on 
February 09, 2023. 
 
You asked the Plan to pay for nursing facility care and nail debridement. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care and 
nail debridement provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve podiatry services. You say that it is medically necessary. The Plan denied 
your request. The Plan says you must receive your care from a network provider. In most cases, care you 
receive from an out-of-network provider will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 Transmitter. You say that this continuous glucose monitor is 
medically necessary. The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Dexcom G6 Transmitter. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
Transmitter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary closure of a sinus perforation for upper left 
quadrant (D7261) and placement of intra-socket dressing (D7922). 
 
You asked the Plan to pre-approve 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 pre-approve 
primary closure of a sinus perforation for upper left quadrant (D7261) and placement of intra-socket dressing 
(D7922).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower dentures. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 March 14, 2023. 
Therefore, we decided that the Plan does not have to pre-approve upper and lower dentures.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, & 87900) provided on October 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
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 find that CPT codes 87798, & 87900 are not supported in the medical record. Specifically, lab results are 
not included for the billed codes. The number of units billed for code 87798 is not supported. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87798, & 87900) provided on October 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 
20, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transport services. You say that you were 
wheelchaired to an 8-passenger van and there was no evidence that this van was an ambulance. You also say 
that it's not fair to be charged this amount. 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 $285 
copayment for each in and out-of-network Medicare-covered one-way trip via ground ambulance.  
 You have been asked to pay a $285 copayment for the ambulance transport services. This /service falls within 
the ambulance 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 copayment for the 
ambulance transport provided on March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided on December 21, 
2022. 
 
You asked the Plan to pay for polycarbonate lenses (V2784) . You say that you were told that you have $100 to 
spend on prescription eyeglasses. You also say you spent only $77. The Plan denied your request. The Plan 
says the claim was processed correctly with the applicable copayment. 
 
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 they are basic CR-39 clear plastic single vision, lined bifocal, or 
trifocal lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there $0 copay for up to 1 pair of 
eyeglasses (lenses and frames), with CR-39 clear plastic single vision, lined bifocal, or trifocal lenses per 
calendar year. The Plan rules also say the Plan pays up to $100 per calendar year for eyeglasses (lenses and 
frames). The Plan rules also say that in addition to the benefits listed above, the Plan offers a 15% discount off 
usual and customer charges for eyeglass lens treatment upgrades.  
 
You have been asked to pay $26.35, which is balance after the discount of 15% off the allowed amount of 
polycarbonate lenses (V2784) ($31 allowed amount x 15% = $26.35). 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. Based on this information, we decided that the Plan's rules for 
coverage of polycarbonate lenses (V2784)  have not been met. Therefore, we decided that the Plan does not 
have to pay for polycarbonate lenses (V2784) provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a miscellaneous vision item or service (V2799) provided on 
August 10, 2022. 
 
You asked the Plan to pay for a miscellaneous vision item or service (V2799). You say that this was declined 
as "lens option non-covered without purchase of a base lens. You also say that this was eye drops. The Plan 
denied your request. The Plan says according to the 2022 EOC, there is not coverage for eye drops. 
 
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 a routine eye examination and a frames and lens package. 
 
We looked at the file and the Plan's rules. The Plan rules say that vision care coverage includes a routine eye 
examination and a frames and lens package. The Plan rules also say that Prescription drugs or pre-medications, 
whether dispensed or prescribed are excluded from this benefit. This includes eye drops. Based on this 
information, we decided that the Plan's rules for coverage of a miscellaneous vision item or service (V2799) 
have not been met. Therefore, we decided that the Plan does not have to pay for a miscellaneous vision item or 
service (V2799) provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating they are 
wanting the denial for the entire claim to be reviewed as there was no authorization prior. The Plan denied your 
request. The Plan says Medicare rules say that health Plans can require enrollees to get care from network 
providers. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 8, 2023, by an 
out-of-network (OON) provider.