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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(A0429), and ground mileage (A0425) provided on May 2, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the medical records 
provided support the need for the requested ambulance services. The Plan denied your request. The Plan says 
the enrollee was an inpatient at time of transport. 
 
The Plan must follow Medicare rules. Medicare rules say that that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider.  
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Based on this information, we decided that Medicare rules for coverage 
of the ambulance service and ground mileage have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance service, basic life support, emergency transport (A0429), and ground mileage 
(A0425) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital hearing aids provided on May 5, 2023. 
 
You asked the Plan to pay for digital hearing aids. You say that when you called to check on coverage, you did 
not hear the representative state the change in covering. The Plan denied your request. The Plan says the 
hearing aids were purchased from a provider which is not an in-network provider with the 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 the hearing aids are obtained through a Plan hearing network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of digital hearing aids have not been met. Therefore, we decided that the Plan does not have to pay 
for digital hearing aids provided on May 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept (A0432) provided on April 3, 2023. 
 You asked the Plan to pay for the paramedic intercept. You say that your husband had ambulance services on 
March 20, 2023 and only had a $275.00 copay. You also say that you and your husband live alone and there 
was no other way to get him to the hospital because he was weak and on oxygen. The Plan denied your request. 
The Plan says the enrollee's 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 the 
paramedic intercept (A0432) provided on April 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
25, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not understand 
why you had to be transferred to another 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the 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 the ambulance 
services provided on June 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the peri-implant capsulectomy, of the 
breast, complete, including removal of all intracapsular contents (19371) and the removal of a ruptured breast 
implant, including implant contents (19330) provided on April 18, 2023. 
 
You asked the Plan to issue reimbursement 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 the services are 
not payable as the provider is not enrolled in the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue reimbursement for the peri-implant 
capsulectomy, of the breast, complete, including removal of all intracapsular contents (19371) and the removal 
of a ruptured breast implant, including implant contents (19330) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on March 30, 2023. 
 You asked the Plan to pay for anesthesia services. You say that the enrollee's hospice ended on March 28, 
2023, and the claim should be reprocessed for the full appropriate payment. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 28, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator (E1390), and the delivery and 
set-up (E1399) purchased on April 6, 2023. 
 
You asked the Plan to pay for the portable oxygen concentrator and the delivery and set-up. You say that you 
needed a portable oxygen concentrator due to the heavy and cumbersome portable oxygen tank you already 
have. You also say that once the item was purchased, you contacted the plan and were provided a 
reimbursement form and were advised services would be reimbursable. The Plan denied your request. The Plan 
says the portable oxygen concentrator (E1390), and the delivery and set-up are not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
 
 In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for a portable oxygen 
concentrator (E1390), and the delivery and set-up (E1399) purchased on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on June 16, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the hearing benefit is not covered if the services are not registered in 
advance. The Plan also says that hearing aids ordered through providers other than the Plan Hearing are not 
covered. 
 
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 the hearing aids are obtained through a Plan hearing network provider. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images and the topical 
application of fluoride (D1208, D0350) provided on June 16, 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 the services denied correctly as they do not fall 
within your 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 2D 
oral/facial photographic images, and the topical application of fluoride (D1208, D0350) provided on June 16, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
May 26, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you disagree with 
the 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 $285 
copayment for ambulance services. 
 
You have been asked to pay a $285 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. However, since the allowed amount is less than the standard copayment, you only owe 
$269.33. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
transportation provided on May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,500 annual maximum 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 $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 26, 2023, and billed with codes 87481, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on January 26, 2023, and billed with codes 87481, 87798, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lenses (V2204) and anti-reflective coating (V2750) 
provided on May 22, 2023. 
 
You asked the Plan to pay for bifocal lenses (V2204) and anti-reflective coating (V2750). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a total of $250 every 2 years for eyeglasses from participating network 
providers. The Plan contract also says that you are responsible for costs above the Plan limit. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover up to a total of $250 every 2 years for 
eyeglasses from participating network providers. The Plan contract also says that you are responsible for costs 
above the Plan limit. The record shows this benefit was exhausted on dates of service April 4, 2022, and May 
22, 2023. Based on this information, we decided that the Plan's rules for coverage of bifocal lenses (V2204) 
and anti-reflective coating (V2750) have not been met. Therefore, we decided that the Plan does not have to 
pay for bifocal lenses (V2204) and anti-reflective coating (V2750) provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) and the manual therapy/ 
lymphatic drainage (97140) provided from March 13, 2023, to March 20, 2023. 
 
You asked the Plan to pay for the electrical stimulation (G0283) and the manual therapy/lymphatic drainage 
(97140). You say that you have been suffering with chronic pain for many years caused by lumbar stenosis and 
arthritis. You say the doctor say the treatments were medically necessary. The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
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 the electrical stimulation (G0283) and the manual therapy/lymphatic drainage 
(97140) provided from March 13, 2023, to March 20, 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 June 26, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health care services. You say that the service rendered 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 service rendered was 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 June 
26, 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 panoramic imaging (D0330), and intraoral imaging 
(D0220/D0230) provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you fell and hurt your face. You say that this 
dental visit was medically necessary. 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 D0330 was exhausted on date of service December 19, 2019, and D0220 and D0230 was exhausted on May 17, 2023. Therefore, we decided that the Plan does not have to pay for panoramic 
imaging (D0330), and intraoral imaging (D0220/D0230) provided on June 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced life support (Als), level 2 (A0433) provided on 
June 7, 2023. 
 
You asked the Plan to pay for Als 2 (A0433). You say that the call was dispatched as an emergency transport. 
You also say that Als 2 procedures were performed. The Plan denied your request. The Plan says because the 
Medicare ambulance benefit is a transport benefit, if no transport happens 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 June 7, 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 advanced life support (Als), level 2 (A0433) 
provided on June 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(A0429), and ground mileage (A0425) provided on June 15, 2023. 
 You asked the Plan to pay for the ambulance service and ground mileage. You say that the medical records 
provided support the need for the requested ambulance services. 
The Plan denied your request. The Plan says the enrollee was receiving inpatient hospital care at the time of the 
transport 
 
The Plan must follow Medicare rules. Medicare rules say that that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider.  
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance service and ground mileage have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance service, basic life support, emergency transport (A0429), and ground mileage (A0425) 
provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bridge impression (D6000) for tooth #6 provided on 
September 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had an accident, and the dental service was 
medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the bridge impression 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 bridge 
impression (D6000) for tooth #6 provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the intraoral 
complete series of radiographic images (D0210) provided on October 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 the Plan paid for a comprehensive oral evaluation (D0150) and the intraoral complete series of 
radiographic images (D0210) on June 11, 2021; therefore, your benefit for the requested items or services was 
exhausted on the date of service of June 11, 2021. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) and the intraoral complete series of radiographic images (D0210) 
provided on October 21, 2022.