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

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213), mandibular partial 
denture (D5214). 
 
You asked the Plan to pre-approve maxillary partial denture and mandibular partial denture. You say that you 
had teeth removed already to put the denture in place. 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 
maxillary partial denture (D5213), mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral comprehensive series (D0210) provided on June 15, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you have not exhausted this benefit. 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 with the approved and paid D0330 provided on date of service June 15, 2023. Therefore, we decided that the Plan does not have to pay for intraoral comprehensive series 
(D0210) provided on June 15, 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 the requested dental item is 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 dental item is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper 
partial denture (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on February 10, 
2023. 
 
You asked the Plan to pay for the CxBladder testing (0013M). 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. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0013M) provided on February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545 and 
A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are supposed to be getting the 
compression stocking and they should be approved. The Plan denied your request. The Plan says the denial of 
authorization is correct, because you do not meet the Medicare guidelines for the compression stocking of 
A6545 and A6530 is a non-Medicare covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
and A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say 
that compression bandages and gradient compression wraps are covered only when they are used as dressings 
over a qualifying wound. The rules say that compression stockings described by code A6530 are noncovered 
because they do not meet the statutory definition of a surgical dressing. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings with code A6545 can be covered or paid for 
by Medicare. Although the compression stockings with code A6530 may be appropriate, it does not fall into a 
covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan 
does not have to pre-approve compression stockings identified with code A6545 and A6530.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on January 
6, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were assisted for a 
fall, and the ambulance treatment should be covered. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 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 ambulance treatment without transport provided 
on January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. 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 pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported crown (D6061) provided on March 27, 2023. 
 
You asked the Plan to pay for D6057 and D6061. You say that services should be covered even if provided by 
an out-of-network provider. The Plan denied your request. The Plan says the denied services are not covered 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 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 a custom 
fabricated abutment (D6057) and an abutment supported crown (D6061) provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fused crown (D2751) provided on May 12, 2023. 
 
You asked the Plan to pay for D2751. You say that you needed this dental work. The Plan denied your request. 
The Plan says these services have been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers D2751 when 
the services are medically necessary and reasonable.  
 
 We looked at the file and Medicare rules. The Plan has correctly applied a 50% coinsurance of the allowed 
amount, and the difference between the less expensive alternative. Based on this information, we decided that 
the Plan's rules for coverage of D2751 have not been met. Therefore, we decided that the Plan does not have to 
pay for a fused crown (D2751) provided on May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87500, 87563, 87640, 87641, 
87653, 87798) provided on April 26, 2023. 
 
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 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 codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798 are not supported in the 
medical record. Specifically, multiple unbundled codes were billed for a single panel. 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 (87481, 87491, 87500, 87563, 87640, 87641, 87653, 
87798) provided on April 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on March 3, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were not aware that 
the services would not be covered. The Plan denied your request. The Plan says the Medicare ambulance 
benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 3, 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 treatment without transport provided 
on March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions-one to 
three teeth or tooth spaces, per quadrant (D7321) provided on May 15, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service at issue is not payable as it was 
rendered by an out-of-network provider.  
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal.   
 
 
 
 
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
this service. Therefore, we decided that the Plan does not have to pay for the alveoloplasty not in conjunction 
with extractions-one to three teeth or tooth spaces, per quadrant (D7321) provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 3, 2023. 
 
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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #19 provided on May 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that the tooth had to be removed and if you did not 
get a crown, you would not be able to eat. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because the crown 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 a crown 
(D2740) for tooth #19 provided on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
porcelain/ceramic crown (D2740), the extractions, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210 x 3), and the resin-based composite-three surfaces, posterior (D2393) provided on 
June 14, 2023. 
 
You asked the Plan to pay for these items/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 items/services 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 items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup, including any pins when required (D2950), porcelain/ceramic crown (D2740), the extractions, of an 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 3), and the resin-based composite-
three surfaces, posterior (D2393) provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on June 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit that was provided 
out of the United States of America on December 20, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were out of the 
country, and you had a medical emergency and the services should be covered. 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 $90 
copayment for worldwide emergency/urgent coverage and worldwide emergency transportation.  
 
  You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
urgently needed 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 an 
emergency room visit that was provided out of the United States of America on December 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on July 15, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that ambulance services where there is no transport are not a 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 15, 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 ambulance services without transport received on 
July 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on May 30, 2023, by an out-of-
network (OON) provider.  
  You asked the Plan to pay for the home health visit. You say that you would like the claim reprocessed for 
payment and the services was 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 a home health visit provided on May 30, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on August 10, 
2022. 
 
You asked the Plan to pay for an office visit. You say that that you were approved for 36 treatments. The Plan 
denied your request. The Plan says The Plan says that an office visit is not a covered benefit when billed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor.  
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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. No clinical records were provided to show that the enrollee is insulin 
treated or has problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 12, 
2023. 
 You asked the Plan to pay for procedure code 93042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 12011. 
 
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 code 93042 
is a column II code to column I code 12011. 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 code 93042 billed for date of service April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on May 1, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
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 issue reimbursement for  care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.  
  
 
 
 
 
We found no exception that would require the Plan to issue reimbursement for these items. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids purchased on May 1, 2023.