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

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on June 13, 
2023, to June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the providers who were in network were too far 
away. 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 dental services provided by an OON provider on June 13, 2023, to June 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 12, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that at the time of service you did not have the 
billing information for the enrollee. The Plan denied your request. The Plan says the timeline for filing has 
expired. 
 
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 ambulance services was not filed until May 24, 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 ambulance services provided on March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for onlay - porcelain/ceramic (D2644) provided on May 22, 
2022. 
 
You asked the Plan to pay for onlay - porcelain/ceramic. You say that this should be covered. 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 pay for onlay - 
porcelain/ceramic (D2644) provided on May 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full set x-rays (D0210) provided on August 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that when you switched offices, they did the x-rays 
again. 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 December 29, 2021. 
Therefore, we decided that the Plan does not have to pay for full set x-rays (D0210) provided on August 11, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van (A0130) and mileage (S0209) provided on 
June 27, 2023. 
 
You asked the Plan to pay for wheelchair van (A0130) and mileage (S0209). You say that the member should 
not have been denied per a Plan representative. You also say that this should be covered with 10% coinsurance, 
not the full amount. The Plan denied your request. The Plan says there is no coverage for non-emergency 
transportation when received from a provider other than the Plan transportation in-network provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 
  The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van (A0130) and mileage (S0209) provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal and bacterial infection polymerase chain reaction 
(PCR) panel provided on May 26, 2023, and billed with codes 87798, 87481, and 87551. 
 
You asked the Plan to pay for the fungal and bacterial infection 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 fungal and bacterial infection PCR 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the fungal and bacterial infection polymerase chain reaction (PCR) panel provided on May 26, 2023, and billed with codes 87798, 
87481, and 87551.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (EM) services (99291)
provided to the enrollee from July 27, 2022, to July 28, 2022.

You asked the Plan to pay for the EM services. You say that the claim was billed correctly and should be paid.
The Plan denied your request. The Plan says that documentation does not support the billed code. Maximus
overturned the Plan's denial. The Plan requested a reopening and stated that records were not provided to
corroborate the services. The Plan is correct in this case. The records provided are for the date of service, July
26, 2022, and nothing was provided for the dates in question. 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. Therefore, we decided that the Plan does not have to pay
for the evaluation and management (EM) services (99291) provided to the enrollee from July 27, 2022, to July
28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on July 10, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider should have known that the 
consultation is not covered since they are an in-network provider. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the consultation 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 
consultation (D9310) provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7140) for tooth #31 and to pay for an 
adjunctive pre-diagnostic test (D0431) and an extraction (D7140) for tooth #18 provided on January 30, 2023, 
and March 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you agreed to a plan treatment, and you 
were told the screening test would be no extra cost. The Plan denied your request. The Plan says your annual 
dental maximum benefit for the year has already been exhausted. Also, the adjunctive pre-diagnostic test 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, certain limitations apply. The record 
shows the Plan paid $2,000 for dental services on January 30, 2023; therefore, your annual dental maximum 
benefit for the year was exhausted on the date of service of January 30, 2023. The adjunctive pre-diagnostic 
test is not among covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay more for an extraction (D7140) for tooth #31 and to pay for an adjunctive pre-diagnostic test (D0431) and 
an extraction (D7140) for tooth #18 provided on January 30, 2023, and March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival flap procedure, including root planing - one to 
three contiguous teeth or tooth bounded spaces per quadrant (D4241), osseous surgery (including elevation of a 
full thickness flap and closure)  one to three contiguous teeth or tooth bounded spaces per quadrant (D4261), 
and unspecified periodontal procedure, by report (D4999) provided on February 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered under your 
plan. The Plan denied your request. The Plan says these services are not covered under your 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a gingival 
flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant 
(D4241), osseous surgery (including elevation of a full thickness flap and closure)  one to three contiguous 
teeth or tooth bounded spaces per quadrant (D4261), and unspecified periodontal procedure, by report (D4999) 
provided on February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 provided on May 8, 2023. 
 
You asked the Plan to pay for procedure code 87900. You say that the medical records support the billing of 
procedure code 87900. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 87900. 
 
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 87900 is Infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics.  

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 procedure code 87900. Our reviewer says that the medical 
records do not support the billing of procedure code 87900. Our reviewer found the laboratory report does not 
include documentation of drug susceptibility phenotype prediction, and therefore code 87900 cannot be 
verified. For CPT 87900, the lab analyst measures a patient's susceptibility or resistance to drugs aimed at a 
virus. The test predicts the behavior of the phenotype based on comparing patient data to regularly updated 
genotypic bioinformatics. The clinician can use the information to help in deciding which drugs to prescribe. 
This procedure was not found in report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87900 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87900 provided on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on July 
24, 2023. 
 
You asked the Plan to pay for the dental service. You say that the x-ray was not a normal image for a regular 
checkup, and it was needed to show the area that was going to be extracted. 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 the Plan paid for the intraoral complete series of radiographic images on July 10, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of July 10, 2023. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on July 24, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair or non-routine service for durable medical 
equipment other than oxygen equipment (K0739), integrated drive wheel motors and gear box combinations, 
replacement only (E2370 x2), drive wheel excludes tire (E2394), foam filled drive wheel tire (E2386), and 
wheel lever assemblies (K0108 x2). 
 
You asked the Plan to pre-approve the repair or non-routine service, replacement integrated drive wheel motors 
and gear box combinations, drive wheel excludes tire, foam filled drive wheel tire, and wheel lever assemblies. 
You say that the current wheelchair is less than 5 years old but also no longer under the manufacturer's 
warranty. The Plan denied your request. The Plan says the repair costs are greater than the replacement cost 
and does not meet the Medicare criteria for repairs. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. Medicare rules also say if the expense for repairs exceeds the estimated expense of purchasing or 
renting another item of equipment for the remaining period of medical need, no payment can be made for the 
amount of the excess. 
 
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 repair or non-routine service, 
replacement integrated drive wheel motors and gear box combinations, drive wheel excludes tire, foam filled 
drive wheel tire, and wheel lever assemblies have been met. Specifically, the record shows when the current 
wheelchair was purchased in January 2021, the cost of it was $613.46, and the current repair cost would be 
$,848.94. The Plan attempted to get updated information from the vendor about the current cost of a 
replacement wheelchair, but no response was provided.  Therefore, we decided that the Plan does not have to 
pre-approve the repair or non-routine service for durable medical equipment other than oxygen equipment 
(K0739), integrated drive wheel motors and gear box combinations, replacement only (E2370 x2), drive wheel 
excludes tire (E2394), foam filled drive wheel tire (E2386), and wheel lever assemblies (K0108 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 30, 2023. 
 
You asked the Plan to pay for the dental service. You say that the exam was necessary for a bad tooth. 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 the Plan paid for a limited oral evaluation (D0140) on May 24, 2023, an May 25, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of May 25, 2023. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D6085) on May 3, 2023. 
 
You asked the Plan to pay for the dental service (D6085). You say that you would like to request 
reconsideration of the denied dental service and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the dental 
service (D6085) on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740), core buildup, 
including any pins when required (D2950), and application of desensitizing medicament (D9910) provided on 
July 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have not been to a dentist until this 
year so there is no way you have met your maximum allowance. The Plan denied your request. The Plan says 
your benefit for the requested services $2,000 dollar limit was met. 
 
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. Specifically, 
the benefit for supplemental dental coverage is limited to $2,000 annually. The records show that the Plan paid 
$809.00 under claim number ending in 16610 for dental services provided on July 6, 2023 leaving $1,191.00 
remaining ($2,000 - $809.00 = $1,191.00). The records show that the Plan paid $215 under claim number 
ending in 14220 for dental services provided on July 10, 2023 leaving $976.00 remaining ($1,191.00 - $215.00 
= $976.00). The records show that the Plan paid $421 under claim ending in 66930 for dental services provided 
on July 13, 2022 leaving $555.00 remaining ($976.00 - $421.00 = $555.00). You had used all but $555.00 of 
that amount on previous dates. After the claim for date of service July 14, 2023 was processed you have a 
liability of $1,464.00 The total claim was $2,019.00 - $555.00 = $1,464.00. This means that the Plan paid 
$2,000 in total for dental services provided in 2023. Therefore, we decided that the Plan does not have to pay 
more for the crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), and 
application of desensitizing medicament (D9910) provided on July 14, 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 
February 17, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799 and 87900. 
 
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 February 17, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799 and 87900.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraorifice barrier (D3911) provided on July 12, 2023. 
 
You asked the Plan to pay for the intraorifice barrier. You say that you believe you plan includes x-rays and 
basic cleaning. The Plan denied your request. The Plan says this service is not covered under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraorifice barrier (D3911) provided on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 6, 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 $2,000 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 5, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
needed the immediate care that was offered as you are a heart patient. You also say that the emergency medical 
service performed an electrocardiogram and told you transport to the hospital was not necessary. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
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 5, 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 with no 
transport provided on June 5, 2023.