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

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), bitewing x-rays-four 
radiographic images (D0274), periodic oral evaluation (D0120), intraoral-periapical first radiographic image 
(D0220), and the intraoral-periapical additional radiographic images (D0230 x 2) provided on March 28, 2023. 
 
You asked the Plan to pay for the dental 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 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 cleaning (D1110), bitewing x-rays-four radiographic images (D0274), periodic oral evaluation (D0120), 
intraoral-periapical first radiographic image (D0220), and the intraoral-periapical additional radiographic 
images (D0230 x 2) provided on March 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional mileage traveled on September 1, 2023. 
 
You asked the Plan to pay for the additional mileage. You say that it was the physician's decision on where to 
transfer the enrollee. The Plan denied your request. The Plan says there was a closer facility available to treat 
the enrollee at the time of service.  
The Plan must follow Medicare rules. Medicare rules say that transport to the nearest treating facility is 
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the additional mileage have not been met. Therefore, we decided that the Plan does not have to pay 
for additional mileage traveled on September 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92014 provided on August 1, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 92014. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 procedure code 92014 provided on August 1, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the pontics (D6245 x 2), retainer crowns (D6740 x 3), 
crowns (D2740 x 2) and core buildup (D2950) provided from August 16, 2023, to August 22, 2023. 
 
You asked the Plan to pay more for the dental services. You say that these procedures were necessary due to 
the age of your old bridge and decay causing pain. You cannot afford these on your fixed income and thought 
your dental benefits would cover part of the cost. The Plan denied your request. The Plan says these services 
are not covered benefits under your dental plan and the 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 50% 
coinsurance for these dental services. 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 50% coinsurance for the crowns (D2740 x 2) and core buildup (D2950). These 
items/services fall within the dental 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the pontics (D6245 x 2) and retainer 
crowns (D6740 x 3) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay more for the pontics (D6245 x 2), retainer crowns (D6740 x 3), crowns (D2740 x 2) and core 
buildup (D2950) provided from August 16, 2023, to August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on July 27, 2023, from a non-Plan 
approved vision care provider. 
 
You asked the Plan to pay for the eyeglasses. You say that you cannot afford the Plan-approved providers 
because they are too expensive. You also say that you would like the Plan to reimburse you $200. The Plan 
denied your request. The Plan says the provider you purchased this eyewear from is not an in-network vision 
care provider. 
 
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 these services when they are a provided by a Plan-approved routine vision care 
provider. 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received this eyewear from a 
provider who is not a Plan-approved vision care provider. Based on this information, we decided that the Plan's 
rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to 
pay for the eyeglasses purchased on July 27, 2023, from a non-Plan approved vision care provider.  
 
Your complaint about the Plan being unfair with their reimbursement policy is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 29, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have given all the required 
documents to support payment for the claim. The Plan denied your request. The Plan says the documentation 
requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. There was no signed receipt of the delivery. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on July 15, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the provider is in network 
with the Plan. The Plan denied your request. The Plan says the chiropractic manipulative treatment is available 
in network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment provided 
on July 15, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on July 10, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that procedure code 
99284 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for an emergency department visit (procedure 99284). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found the documentation provided supports an appropriate exam but does not support an appropriate history or 
moderate level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99284) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99284) 
provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laser in situ keratomileusis (lasik) surgery. 
 
You asked the Plan to pay for the lasik procedure. You say that due to a year of required follow up 
appointments May 1, 2023, should start the one-year mark for claim consideration. The Plan denied your 
request. The Plan says this service has been denied because the request for payment was received more than 12 
months after the date of service. 
 
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 the lasik procedure was not filed until May 11, 2023. 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 the laser in situ keratomileusis (lasik) surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, of a molar tooth (excluding final 
restoration) (D3330) provided on July 26, 2023. 
 
You asked the Plan to pay for this dental 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 dental service was received from an 
out-of-network provider and is 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 dental service from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the service provided is 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 endodontic therapy, of a molar tooth 
(excluding final restoration) (D3330) provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown 
(D2954) provided on July 3, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the item provided 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 item provided was exhausted on date of service July 3, 2023.  
  
Specifically, the Plans contract states that the annual maximum allowable dental benefit is $2,000. The Plan 
issued payment in the amount of $2,000 ($1,967 + $33) for dental services provided in the 2023 calendar year. 
Therefore, you have exhausted the allowable benefit for the dental item provided in this case. Therefore, we 
decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954) 
provided on July 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 4, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for home exercise equipment provided on August 27, 
2023. 
 
You asked the Plan to reimburse for home exercise equipment. You say that you were specifically told the 
reimbursement for home exercise equipment was $200 per your Plan. You also said that you were told that 
each of you in the home with the same Plan would receive the $200 reimbursement, for a total of $600. The 
Plan denied your request. The Plan says according to your EOC, they will provide up to $100 every year 
towards your wellness reimbursement. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses up to 
$100 for your wellness benefit. 
 
 
  The Plans rules for coverage of gym benefits have been exhausted with this date of service. Therefore, we 
decided that the Plan does not have to reimburse for home exercise equipment provided on August 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #3 provided on September 7, 
2023. 
 
You asked the Plan to pay for the dental service. You say that when you switched your dental coverage also 
switched and you would like to appeal the denied crown. 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 #3 provided on September 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic angiography (CTA) scan of 
abdominal aorta and both leg arteries. 
 
You asked the Plan to pre-approve the CTA. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the scan is not medically necessary at this time.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CTA. Our reviewer says that the 
CTA is not medically necessary. Our physician reviewer found the enrollee has documented left carotid bruit 
and possible right subclavian steal syndrome based on the ultrasound. The ordered CTA current procedural 
terminology (CPT) 75635 is related to the abdominal aorta and lower extremity arteries. The correct order 
would have been CPT 71275, CTA of the thoracic aorta. The requested CTA is not medically necessary at this 
time. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomographic angiography (CTA) scan of abdominal aorta and both leg arteries.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on August 2, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary but given your improvement there was no need to go to the emergency 
room. The Plan denied your request. The Plan says without transport there is no payable services. 
 
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 2, 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 without 
transport services received on August 2, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred medications.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires that one of the preferred 
Visco supplemental treatments (Orthovisc, Synvisc/ Synvisc-One, or Monovisc) be trialed first. The 
documentation does not outline contraindications or reasons these medications were not considered or that the 
plan's additional required drugs would likely be less effective or have adverse effects for the enrollee. Without 
the support of the documentation, Euflexxa is not approved as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on September 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there are 
no payable services. 
 
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 September 15, 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 without 
transport services received on September 15, 2023.