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

 
We decided that the Plan does not have to pay for treatment with bupivacaine provided on June 29, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (62323) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for treatment with bupivacaine provided on June 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 11, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you say that you disagree 
with the amount charged. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for ambulance services. This item/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 ambulance services 
provided on July 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
29, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the health issue was not 
resolved and you should not have to pay. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for an emergency room visit. This item/service falls within the 
emergency care 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 an emergency room visit 
provided on May 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine disposable supplies (A0398) provided on February 
28, 2023. 
 
You asked the Plan to pay for the ambulance supplies. You say that you were transported to the emergency 
room and stayed overnight for cardiac observation. The Plan denied your request. The Plan says this service is 
not covered under any circumstance by the health plan or Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for routine disposable supplies (A0398) provided on February 
28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive series of radiographic images (D0210) 
provided on July 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this imaging. 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 D0210 was exhausted on date of service February 24, 2022 with the approved and paid 
D0330. Therefore, we decided that the Plan does not have to pay for comprehensive series of radiographic 
images (D0210) provided on July 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on July 4, 2023. 
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that upon 
returning home from the emergency room, you fell off of your front porch into some bushes. You also say that 
your wife could not get you up, and she called 911 for help. The Plan denied your request. The Plan says if 
there is no transport, then there is no Medicare-covered 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 July 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 ambulance response and treatment, no transport 
(A0998) provided on July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the bone 
replacement graft (D7953), and the consultation (D9310) for tooth #19 provided on June 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary for you to see an oral 
surgeon and you explained to the Plan that you needed to find an oral surgeon. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because the guided tissue regeneration, the 
bone replacement graft, and the consultation are 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. 
 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 the 
guided tissue regeneration (D4266), the bone replacement graft (D7953), and the consultation (D9310) for 
tooth #19 provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 25, 
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 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 February 23, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
August 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), anti-reflective coating (V2750), bifocal 
lenses (V2200) and miscellaneous vision services (V2799) provided on June 1, 2023. 
 
You asked the Plan to pay for frames (V2020), anti-reflective coating (V2750), bifocal lenses (V2200) and 
miscellaneous vision services (V2799). You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the benefit Plan does not cover this out-of-network vision care services or 
materials. 
 
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 frames (V2020), anti-reflective coating (V2750), 
bifocal lenses (V2200) and miscellaneous vision services (V2799) provided on June 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Part B drugs and eye surgery on May 11, 
2023. 
 
You asked the Plan to waive the cost share for Part B drugs and eye surgery. You say that you shouldn't have to 
pay these charges. 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 all other Medicare-covered Part B drugs. You must pay a $320 copayment for Medicare-
covered surgery of other services provided to you at an ambulatory surgical center, including but not limited to 
hospital or other facility charges and physician or surgical charges. The provider biller in the amount of 
$1,037.50 and the allowed amount is $384.92 for the services ($384.92 x 20% = $76.98). For both services it's, 
$320 + $76.98 = $396.98. Therefore, results in the total cost sharing amount of $396.98. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and $320 copayment for eye surgery. This 
item/service falls within the Medicare Part B prescription drugs and outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 cost share for Part B drugs and eye surgery on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on July 20, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that the provider confirmed they 
are in network. The Plan denied your request. The Plan says that chiropractic manipulative treatment is 
available in network.  
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 chiropractic manipulative treatment provided on 
July 20, 2023, by an out-of-network (OON) provider.
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 June 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you should not owe anything. 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 June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair or modification of a hearing aid provided on June 
8, 2023. 
 
You asked the Plan to pay for the repair or modification of a hearing aid. You say that you do not understand 
why the provider performed the services if you were not covered for them. The Plan denied your request. The 
Plan says these services are not covered under your medical benefit. The Plan also says they do offer 
supplemental hearing aid coverage, but you did not purchase this supplemental benefit Plan. 
 
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 you purchase a supplemental Plan coverage.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the repair or modification of a hearing aid have not been met. Therefore, we decided that the Plan 
does not have to pay for the repair or modification of a hearing aid provided on June 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal care services provided on March 2, 2023, and 
March 3, 2023. 
 
You asked the Plan to pay for the personal care services. You say that the services were necessary because you 
were denied the continuing treatment at a skilled nursing facility. The Plan denied your request. The Plan says 
the services are a non-covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the 
personal care services provided on March 2, 2023, and March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a urine capacity measurement, and the 
laboratory services. provided on December 01, 2022. 
 
You asked the Plan to pay for an office visit, a urine capacity measurement, and the laboratory services.. You 
say that you are requesting reconsideration of the denied claim. 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 an office visit, a urine 
capacity measurement, and the laboratory services. provided on December 01, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 1, 2023, to 
June 16, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not advised there would be 
a copayment required. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $392 for a SNF stay ($196 per day x 2 days = $392). This item/service falls within 
the SNF care 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 a SNF stay provided from 
June 1, 2023, to June 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on June 27, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you were never notified that 
the chiropractor you seen was out of network. The Plan denied your request. The Plan says that the chiropractic 
manipulative treatment is available in network. 
 
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 chiropractic manipulative treatment provided on 
June 27, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept (A0999) provided on June 22, 2023. 
 
You asked the Plan to pay for the paramedic intercept. You say that you were taken from the home to the 
hospital. The Plan denied your request. The Plan says your coverage does not provide for this ambulance 
service. 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 (A0999) provided on June 22, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine heart study provided 
on May 31, 2023. 
 
You asked the Plan to waive the copayment for the nuclear medicine heart study. You say that you were not 
advised of the full scope of these tests, and were not made aware of the high costs. 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 $300 
copayment for outpatient diagnostic tests and therapeutic services.  
 
You have been asked to pay a $300 copayment for the nuclear medicine heart study. This item/service falls 
within the outpatient diagnostic tests and therapeutic 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 nuclear medicine heart study provided on May 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided on May 23, 2023, by 
an out-of-network (OON) provider.  
  You asked the Plan to pay for the home health care services. You say that you are a contracting provider with 
the facility and the services were medically necessary. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the services rendered 
were not urgent or emergent. 
 
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 the home health care services provided on May 
23, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 9, 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 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 April 18, 2023, and May 
04, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on May 9, 2023.