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

 
We decided that the Plan does not have to pre-approve a visual field examination (92083), gonioscopy (92020), 
and medical eye examination and evaluation (92012) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a visual field examination, gonioscopy, and medical eye examination and 
evaluation. You say that the services should be covered as the provider was on a list of Plan-approved 
Ophthalmologists. The Plan denied your request. The Plan says the requested provider is not one of the Plan's 
network providers. 
 
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 
a visual field examination (92083), gonioscopy (92020), and medical eye examination and evaluation (92012) 
to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal scaling and root planing (D4341) provided on 
August 8, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were under the impression that cleaning was 
covered in full. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the periodontal scaling and root planing 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 
periodontal scaling and root planing (D4341) provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal/reshaping of enamel surfaces or projections 
(odontoplasty) (D9971) provided on August 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that this was not cosmetic. You also say that this 
service was needed to stop your tongue from causing more enamel erosion. 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, this service is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the removal/reshaping of 
enamel surfaces or projections (odontoplasty) (D9971) provided on August 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0427) provided to the enrollee on
December 13, 2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that
this service was billed with a modifier of "RW" which is not an appropriate destination modifier for use with
ET3 ambulance claims. The Medicare Claims Processing Manual - Chapter 15 - Ambulance - Section 30 -
General Billing Guidelines - A) Modifiers specific to Ambulance Service Claims explains how ambulance
services should be billed and what modifiers should be used. A copy of the appealed claim shows the provider
has billed inappropriately. The Medicare Benefit Policy Manual Chapter 10 - Section 10 explains that the
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the
ambulance provider/supplier that furnishes the transport.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly.

In this case, this claim denied due to the omission of the required RP modifier. Medicare rules for payment of
these services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance
services (A0427) provided to the enrollee on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a cleaning (D1110), and 
the application of fluoride (D1208) provided on September 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went for your second check-up and 
cleaning for the calendar year, and you are allowed 2 cleaning a year. The Plan denied your request. The Plan 
says your annual dental maximum benefit for the year 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 $230 for dental services on March 1, 2023. On May 16, 2023, the Plan paid $560 for 
dental services. On June 6, 2023, the Plan paid $210 for dental services. For the year of 2023 the Plan paid 
$1,000 ($230 paid + $560 paid + $210 paid) for dental services; therefore, your annual dental maximum benefit 
for the year of 2023 was exhausted on the date of service of June 6, 2023. Therefore, we decided that the Plan 
does not have to pay for a periodic oral evaluation (D0120), a cleaning (D1110), and the application of fluoride 
(D1208) provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam (D2160) provided on August 8, 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 an 
amalgam (D2160) provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint (V2744) and anti-reflective coating 
(V2750) provided on June 30, 2023. 
 
You asked the Plan to pay for the photochromatic tint and anti-reflective coating. You say that between the 
claim, the health statement, and the provider's breakdown, it does not match. The Plan denied your request. The 
Plan says the $200 annual eyewear allowance was paid by the Plan. 
 
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 up to a $200 allowance every calendar year. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that the Plan applied your full $200 allowance 
toward the eyewear purchased on June 30, 2023. Based on this information, we decided that the Plan's rules for 
coverage of the photochromatic tint and anti-reflective coating have not been met. Therefore, we decided that 
the Plan does not have to pay for the photochromatic tint (V2744) and anti-reflective coating (V2750) provided 
on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided on March 15, 
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 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 the requested item or service was exhausted on date of service February 25, 2019. 
Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided on 
March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the shower chair is to prevent falls and 
substantiate injury. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for custodial care provided from March 27, 2023, to 
August 11, 2023. 
 
You asked the Plan to reimburse you for custodial care. You say that this provider came to your father's home 
while you work and stayed with your father for safety and care. You say that his dementia is currently stage 4 
and being left home alone is not an option. The Plan denied your request. The Plan says the Plan is unable to 
reimburse for non-emergency services received with a provider that does not participate with Medicare. 
Custodial care is not a covered benefit and is clearly excluded in the Evidence of Coverage. 
 
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 reimburse you for custodial care provided from 
March 27, 2023, to August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on August 31, 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 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 the requested item or service was exhausted on date of service May 19, 2023. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator to be provided by an OON provider.  
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration of a 
home ventilator for the enrollee. The Plan denied your request. The Plan says the service can be provided by an 
in-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 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 
a home ventilator to be provided by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 4, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice at the time 
of service. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 30, 2023. 
 
You asked the Plan to pay for lab services. You say that the provider was unable to obtain prior authorization. 
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 lab services provided on 
August 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 2, 2023. 
 
You asked the Plan to pay for ambulance services. You say that you denied transport to the emergency facility 
because you had COVID. The Plan denied your request. The Plan says if no transport of an enrollee occurs, the 
ambulance services are not covered. 
 
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 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 ambulance services provided on September 2, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and unlisted procedure (99199) 
provided on May 31, 2023. 
 
You asked the Plan to pay for the physician services. You say that the provider is in-network. You say that this 
was an error made by the enrollee's Plan. You say that this issue was corrected. You also say that this should be 
reprocessed and paid. The Plan denied your request. The Plan says there is insufficient documentation provided 
to support that the services were actually performed. 
 
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 the physician services have been met. 
Specifically, there were no medical records to support that the services at issue were performed. The record 
shows that the Plan requested these documents, but none were received. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) and unlisted procedure (99199) provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82728, 82746, 84466, and 85045 provided 
on September 26, 2023. 
 
You asked the Plan to pay for procedure codes 82728, 82746, 84466, and 85045. 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 codes 82728, 82746, 84466, 
and 85045 have been met. In this case, the lab order provided did not include the tests described by procedure 
codes 82728, 82746, 84466, and 85045. Therefore, we decided that the Plan does not have to pay for procedure 
codes 82728, 82746, 84466, and 85045 provided on September 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on April 7, 2023. 
 
You asked the Plan to pay for 99285. You say that the original coding is correct. The Plan denied your request. 
The Plan says criteria for 99285 are not met so payment for 99284 will stand. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
We asked our coding 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 pay for 99285. Our reviewer says that this code does 
not meet criteria for payment. Our reviewer found the level of medical decision-making is moderate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99285 have not been met. Therefore, we decided that the Plan does not have to 
pay for an emergency room visit (99285) provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 21, 2023, to 
September 18, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that the enrollee was in a nursing home at the time 
the services were rendered. 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 nursing facility care 
provided on August 21, 2023, to September 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), progressive lens 
(V2781), lens (V2782), vision item or service (V2799 x2), or pay more for the frames (V2020) purchased on 
August 31, 2023. 
 
You asked the Plan to pay for the anti-reflective coating, progressive lens, lens, vision item or service, and to 
pay more for the frames. You say that the Plan initially said the glasses were covered, but you got a statement 
saying the amount charged. You also say if you had known you would not be approved for the glasses, you 
would not have bothered. The Plan denied your request. The Plan says you met your benefit limit with your 
member share totaling $1,058.94. The Plan also says your $100 allowance was applied to codes V2020 and 
V2300 ($50.00 per code) for your eyewear. 
 
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 offers a $100 allowance toward the cost of routine contact lenses or eyewear every year.  
We looked at the file and the Plan's rules. The record show that your full $100 annual eyewear allowance was 
applied toward this eyewear purchase on August 31, 2023, and your eyewear allowance has been exhausted. 
Based on this information, we decided that the Plan's rules for coverage of the anti-reflective coating, 
progressive lens, lens, vision item or service, and to pay more for the frames have not been met. Therefore, we 
decided that the Plan does not have to pay for the anti-reflective coating (V2750), progressive lens (V2781), 
lens (V2782), vision item or service (V2799 x2), or pay more for the frames (V2020) purchased on August 31, 
2023.