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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this 
service should be covered as an essential health benefit. You also say that the enrollee's medical records detail 
medical necessity and warranted the need for an emergent ambulance response on this date of service. The Plan 
denied your request. The Plan says the enrollee refused ambulance transportation. 
 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 August 17, 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 (A0998) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (A9282) purchased on December 30, 2022. 
 
You asked the Plan to pay for the wig. You say that it is your understanding that you are entitled to 
reimbursement of up to $350.00. The Plan denied your request. The Plan says as wigs (also known as cranial 
prosthesis) are considered cosmetic items, and do not fit the conditions for coverage as a prosthetic item or 
device, they are excluded under Medicare and are therefore not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
 In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (A9282) 
purchased on December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(E2103, A4239). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as you do not 
meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies (E2103, A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement procedure provided on November 11, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a debridement procedure. You say that this was medically necessary, and you 
want the bill covered. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 a debridement procedure provided on November 
11, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips.. You say that you do not agree 
with the denial. You also say that the service must be covered since you only use it for your medical 
appointments and that is why you use the service so much. The Plan denied your request.  The Plan says the evidence shows you have used thirty-four (34) one-way trips of the thirty-four (34) one way 
trips covered by your health plan for the year 2023. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 13, 2023. 
 
You asked the Plan to pay for a home visit. You say that there is a referral for this service. 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 a home visit provided on 
January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye exam to be provided by an OON provider.  
 
You asked the Plan to pre-approve an eye exam. You say that you do not want to change providers. The Plan 
denied your request. The Plan says this service can be provided 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 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 eye exam to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the eye exam (92014) provided on March 
8, 2023. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that all you had done was a routine 
vision exam and glaucoma screening, and you would like $30 back since it is only $15 for an eye exam. The 
Plan denied your request. The Plan says it was determined that you had a non-routine eye exam. 
 
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. 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received a medical eye exam, 
and not a routine exam. Based on this information, we decided that the Plan's rules for coverage of the eye 
exam have not been met. Therefore, we decided that the Plan does not have to reduce the copayment for the 
eye exam (92014) provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service March 11, 2021. Specifically, the 
Plans contract states that one upper partial denture is covered every 60 months.  
       
 
 
 
 
You previously received this dental item on March 11, 2021, less than 60 months prior, which was paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for the requested dental item in this case. 
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam (92014) provided on February 21, 
2023. 
 
You asked the Plan to pay for the medical eye exam. You say that you were told by a Plan representative that 
you were covered for an eye exam. You also say that your doctor told you that you were covered. The Plan 
denied your request. The Plan says you are responsible for $40 copayment for each office visit to a specialist. 
The Plan also says that the medical records shows that member received vision care beyond a routine eye 
exam. 
 
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. 
 
 
 We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for multiple 
diagnoses, and not a routine exam. Based on this information, we decided that the Plan's rules for coverage of 
the medical eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the 
medical eye exam (92014) provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown-resin based composite (D2710) and an 
upper partial denture (D5225). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested denture has already 
been exhausted. Additionally, the dental crown requested in this case 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, certain limitations apply. The record 
shows your benefit for the requested denture was exhausted on date of service March 24, 2020.   
 
 
 
Specifically, the Plans contract states that one complete or partial denture is covered per arch every five years. 
You previously received an upper partial denture on March 24, 2020, less than five years prior, which was paid 
for by the Plan. Therefore, you have exhausted the allowable benefit for the requested denture in this case. 
Additionally, a resin based composite dental crown is not a covered benefit under the supplemental dental 
policy. Therefore, we decided that the Plan does not have to pre-approve a dental crown-resin based composite 
(D2710) and an upper partial denture (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
September 21, 2022. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should be billed at 
the in-network benefit level. 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 $70 
copayment for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $70 copayment for the specialist office visit. This item/service falls within the out-of-network physician/practitioner services, including doctors office visits 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 copayment for the specialist office visit provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
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 requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on February 1, 
2023. 
 You asked the Plan to pay for paramedic intercept services. You say that you would like reconsideration 
because the requested paramedic intercept services are medically necessary. The Plan denied your request. The 
Plan says the requested paramedic intercept services are not a covered benefit. 
 
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 the 
paramedic intercept services provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service November 10, 2022. Specifically, 
the Plans contract states that complete or partial dentures are covered once per arch every 60 months.  
  
 
 
You previously received an upper partial denture on November 10, 2022, less than 60 months prior, which was  
paid for by the Plan. Therefore, you have exhausted the allowable benefit for the requested dental item in this 
case. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 & 87653 billed for date of service 
November 16, 2022. 
 You asked the Plan to pay for procedure codes 87481 & 87653. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for codes 87481 & 87653 is bundled into 
payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481 & 87653 are column II codes to column I code 87801. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481 & 87653 billed for date of 
service November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 3, 2023, billed with 
codes 81218, 81209, 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81334, 81314, 81345, 
and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 3, 2023, billed with codes 81218, 81209, 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, 81334, 81314, 81345, and 81272.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83695 provided on June 13, 2022. 
 
You asked the Plan to pay for procedure code 83695. 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of procedure code 83695 have been met. 
There were no medical records provided for review to determine if these services were medically necessary. 
Therefore, we decided that the Plan does not have to pay for procedure code 83695 provided on June 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a self-administered drug.  
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a self-administered drug.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement to enable a comprehensive 
oral evaluation and diagnosis on a subsequent visit (D4355). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested 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.  
 
  
 
 
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plans contract states that the requested service in 
this case is not covered when performed less than one calendar year after an evaluation. The enrollee 
previously received a comprehensive oral evaluation on March 6, 2023, less than one year prior. Therefore, the 
enrollee does not meet criteria for coverage of the requested service. Therefore, we decided that the Plan does 
not have to pre-approve a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a 
subsequent visit (D4355).