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

 
We decided that the Plan does not have to pay for implant placement (D6010) for tooth #10 provided on March 
16, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the implant 
placement 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant 
placement (D6010) for tooth #10 provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic retention (D8680) provided on February 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the retainers were medically necessary because 
your previous ones were worn out. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the orthodontic retention 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. 
 
  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 
orthodontic retention (D8680) provided on February 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure provided on October 20, 2022. 
 
You asked the Plan to pay for therapeutic procedure. You say that you are requesting the submitted 
documentation be reviewed. 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 therapeutic procedure 
provided on October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a prophylaxis - adult (D1110), and periodic oral 
evaluation - established patient (D0120) provided on November 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are asking for reconsideration for 
reimbursement for the services rendered. 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 prophylaxis - adult (D1110), and periodic 
oral evaluation - established patient (D0120) provided on November 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 6, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport . You say that you 
would like to appeal the ambulance denial as this is not a valid reason. You also say that you have received 
ambulance service form this company before from this location. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
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 March 6, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography scan provided 
on February 09, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography scan. You say that you were told 
you would not have a copayment. 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 $175 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for the computed tomography scan. This item/service falls within the in-network outpatient diagnostic tests and therapeutic services and 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. However, you only owe 
$173.01, which is less than the standard copayment. Therefore, we decided that the Plan does not have to waive 
the copayment for the computed tomography scan provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the pacemaker programming services 
provided on February 2, 2023. 
 
You asked the Plan to waive the deductible for the pacemaker programming services. You say that this should 
not have a deductible. 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. Your 
contract with the Plan says that there is a $100 deductible which applies to primary care provider office visits. 
Your contract with the Plan also clearly says that you must pay a $15 copayment after meeting the deductible 
for primary care provider office visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible which applies to primary care provider office visits. This cost sharing is a contractual 
obligation that had not been met at the time the pacemaker programming services was received on February 2, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the pacemaker 
programming services provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin based composite tooth 18 and 19 (D2391) 
provided on November 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 resin based composite tooth 18 and 19 
(D2391) provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an emergency response system (S5161). 
 
You asked the Plan to pre-approve an emergency response system. The Plan denied your request. The Plan says 
that this service is not covered under your Medicare plan. 
 
The Plan must follow Medicare rules. Medicare does not pay for over-the-counter (OTC) items, however, your 
plan offers a supplemental benefit for OTC items. 
 
We looked at the file and Medicare rules. While Medicare does not pay for OTC items like the PERS, the Plan 
offers a supplemental benefit for this item. The Plan contract rules clearly say that this item is covered under 
the OTC benefit, up to a maximum of $475 per quarter. The Plan has also advised that your benefit limit for the 
OTC coverage has not been exhausted. Based on this information, we decided that Medicare rules for coverage 
of an emergency response system have been met. Therefore, we decided that the Plan has to pre-approve an 
emergency response system (S5161).  
 
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 pre-approve a crown - porcelain/ceramic (D2740), unspecified 
restorative procedure, by report (D2999), bone replacement graft for ridge preservation - per site (D7953), and 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services represented by codes D2740, D2999, D7953 and D5214. 
You say that you are missing a tooth and need to get a permanent crown. You also say that you need the other 
procedures done due to the pain you are experiencing. The Plan denied your request. The Plan says if a 
procedure isn't listed in the chart, it isn't covered. 
 
 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 a 
crown - porcelain/ceramic (D2740), unspecified restorative procedure, by report (D2999), bone replacement 
graft for ridge preservation - per site (D7953), and mandibular partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical technician checked your vitals and never offered or mentioned going to the hospital. You 
also say that you were unaware that not going to the hosptial meant that it would not be covered. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
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 December 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant placement (D6010), custom abutment 
(D6057), the abutment supported to crown (D6062) for tooth #13. 
 
You asked the Plan to pre-approve the dental services. You say that your tooth is broken, and the dentist 
recommended an implant to fix the dental issue. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the implant placement, custom abutment, the abutment 
supported to crown 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 pre-approve the 
implant placement (D6010), custom abutment (D6057), the abutment supported to crown (D6062) for tooth 
#13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on October 27, 2022.  
 
You asked the Plan to pay for foot orthotics. You say that you have back related problems, and the shoes were 
recommended. 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 October 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213-25) provided on August 31, 2022. 
 
You asked the Plan to pay for the office visit (99213-25). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99213-25 is not supported in the medical record. The office visit at issue was billed 
with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management 
(EM) service by the same physician or other qualified health care professional on the same day of a procedure 
or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to 
the treatment provided to the enrollee on this date of service. Therefore, we decided that the Plan does not have 
to pay for the office visit (99213-25) provided on August 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 22, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the transportation 
should be waived because you were admitted to the hospital. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. 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 the 
ambulance transportation provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement grafts for ridge preservation-per site 
(D7953 x 2), the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth  
(D7210 x 2), and the consultation-diagnostic service (D9310) provided on February 16, 2023. 
 
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 these services are not covered under your 
supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement grafts for ridge preservation-per site (D7953 x 2), the extractions, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210 x 2), and the consultation-diagnostic service (D9310) 
provided on February 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 11, 2021, to 
May 13, 2021. 
 
You asked the Plan to pay for inpatient hospital services. You say that the enrollee gave you the incorrect 
insurance information. The Plan denied your request. The Plan says this appeal was not filed timely. 
 
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 inpatient hospital services was not filed until July 20, 2022. 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 inpatient hospital services provided on May 11, 2021, to May 13, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided on January 09, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the PT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not medically necessary.  
 
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 physical therapy (PT) services provided on 
January 09, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prodigy test strips, SteriLance lancets, and Prodigy 
control solution provided on May 16, 2022. 
 
You asked the Plan to pre-approve the Prodigy test strips, SteriLance lancets, and Prodigy control solution. You 
say that these services are a medical necessity. The Plan denied your request. The Plan says only the preferred 
brand products listed in the EOC are covered. The Plan also says that there was no documentation provided to 
support the medical necessity of a non-LifeScan/OneTouch product. 
 
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 the Prodigy test strips, Sterilance lancets, and Prodigy  control solution. Therefore, we decided that the Plan 
does not have to pre-approve Prodigy test strips, SteriLance lancets, and Prodigy control solution provided on 
May 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the pembrolizumab injection provided on 
December 2, 2022, and December 22, 2022. 
 
You asked the Plan to reduce the coinsurance for the injection. You say that you were not informed of the high 
cost. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 
 You have been asked to pay $2,042.06, which is 20% coinsurance of the allowed amount for the injection 
provided on December 2, 2022 ($10,210.29 allowed amount x 20% = $2,042.06). You have also been asked to 
pay $1,618.37, which is less than 20% coinsurance of the allowed amount for the injection provided on 
December 22, 2022. These items/services fall within the Medicare Part B prescription drugs 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 reduce the coinsurance for the pembrolizumab injection provided on December 2, 
2022, and December 22, 2022.