Persius/hicric huggingface dataset:
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 July 16, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you did not want to ride in the ambulance such a short distance and ask for the claim to be overturned. 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 July 16, 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 July 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment rendered on  
October 9, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment.. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says an ambulance 
response without transport is not a 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 October 9, 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 rendered on 
October 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance response without transport provided on July 
24, 2023. 
 
You asked the Plan to pay for an ambulance response without transport. You say that you called the ambulance 
because you were in distress but decided not to go to the hospital when you were told you were fine. The Plan 
denied your request. The Plan says ambulance response without transport is 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 July 24, 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 an ambulance response without transport provided 
on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) and eye refraction (92015) provided 
on June 30, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and eye refraction. You say that you would like the Plan to pay for 
these services. The Plan denied your request. The Plan says the treating provider is not in-network with your 
plan, and you were not referred to this OON provider. The Plan also says that it was confirmed that you did not 
have an approved authorization on file to see the OON provider, and the services were not urgent/emergent. 
 
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 obtained from a provider in the Plans vision vendor 
network. 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received these services from a 
non-contracted provider. Based on this information, we decided that the Plan's rules for coverage of the eye 
exam and eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the 
eye exam (92004) and eye refraction (92015) provided on June 30, 2023, by an out-of-network (OON) 
provider.  
 
Your complaint about being upset with the Plan for not paying for your claims 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 2, 2022. 
 
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 July 2, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection. 
 
You asked the Plan to pre-approve repeat epidural steroid injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not 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 repeat epidural steroid injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation indicating that there was at least 50% improvement of pain or improved function for at least 
three months from the last injection. In addition, NCD guidelines are clear that total number of injections to 
spinal region must not exceed 4 in a 12-month period. The review has determined that the enrollee does not 
meet the LCD criteria for coverage. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services (codes V2020, 92015, 92004, 92499, 
V2784, V2781, V2750, and 92250) provided on August 21, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you believe you are covered and should be 
reimbursed. The Plan denied your request. The Plan says the treating provider and facility are not in-network 
with the Plan's approved routine vision care provider network. The Plan also says that they contacted the 
provider's office and were advised that insurance information was not presented to them at the time of services. 
 
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 performed by a Plan-approved routine vision care provider. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that these services were rendered by a non-
contracted vision care provider. Based on this information, we decided that the Plan's rules for coverage of the 
vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision 
services (codes V2020, 92015, 92004, 92499, V2784, V2781, V2750, and 92250) provided on August 21, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 09, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that the supplies are a separately billable expense. 
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 wound care supplies 
provided on August 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had weakness in their legs and recently 
fell. The enrollee requires IRF services to regain their prior level of functioning and independence. The Plan 
denied your request. The Plan says the request is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ER services provided on February 23, 2022. 
 
You asked the Plan to pay for ER services. You say that this should be covered. The Plan denied your request. 
The Plan says the claim was untimely, so this is not covered. 
 
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 ER services was not filed until August 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 ER services provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the panoramic x-ray the panoramic x-ray (D0330). We decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150), the bitewing x-rays (D0274), the 
intraoral periapical x-rays (D0220x2), and the caries risk assessment (D0603) provided on July 27, 2023.  
 
You asked the Plan to pay for the panoramic x-ray the comprehensive oral evaluation (D0150), the panoramic 
x-ray (D0330), the bitewing x-rays (D0274), the intraoral periapical x-rays (D0220x2), and the caries risk 
assessment (D0603) provided on July 27, 2023. You say that you went to a network dentist and had 
authorization for the services. The Plan says that the benefits have been exhausted for D0150, D0330, D0274, 
and D0220x2 and that D0603 is not a covered benefit. 
 
We decided that the Plan has to pay for the panoramic x-ray the panoramic x-ray (D0330) provided on 
July 27, 2023.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan did not submit records showing that the Plan paid for 
D0330. This means we cannot determine if the benefit has been exhausted. Therefore, we decided that the Plan 
has to pay for the panoramic x-ray .  
 
We also decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the 
bitewing x-rays (D0274), the intraoral periapical x-rays (D0220x2), and the caries risk assessment 
(D0603) provided on July 27, 2023. 
 
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 D0150, D0330, D0274, and D0220x2 was exhausted on date of service January 26, 2023. Though the Plan offers a dental benefit in excess of Medicare coverage, D0603 is not among those 
covered under this benefit. Therefore, the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), the bitewing x-rays (D0274), the intraoral periapical x-rays (D0220x2), and the caries risk assessment 
(D0603) provided on July 27, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12011 for date of service June 29, 2023. 
 
You asked the Plan to pay for procedure code 12011. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 12011 is simple repair of superficial wounds of face, 
ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less. 
 We find that CPT code 12011 is not supported in the medical record. Specifically, code 12011 is identified in 
Addendum AA -- ASC Covered Surgical Procedures for CY 2023 by status indicator N1, which is defined as a 
N1-Pakage service/item; therefore, no separate payments made. Based on this information, we decided that 
Medicare rules for coverage of procedure code 12011 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 12011 for date of service June 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 26, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the cost share is 
wrong. 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 $120 
copayment for emergency room services. 
 
You have been asked to pay a $120 copayment for the emergency room services. This item/service falls within 
the emergency room 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 
emergency room services provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service September 
11, 2023. 
  
 
You asked the Plan to pay for procedure code 96040. You say that 96040 should be paid as billed because 
multiple evaluation and management services can be billed by providers with different specialties, despite 
being in the same billing group. The Plan denied your request. The Plan says procedure code 96040 is 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 96040 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96040 billed for date of service September 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a ferric derisomaltose injection provided 
on August 11, 2023. 
 
You asked the Plan to waive the coinsurance for a ferric derisomaltose injection. You say that no one informed 
you of the cost of this treatment. If you had known, you would not have had it done. 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 20% 
coinsurance for Medicare Part B prescription drugs and related supplies. 
 
You have been asked to pay 20% coinsurance for a ferric derisomaltose injection. This item/service falls within 
the Medicare Part B prescription drugs and related supplies 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. The total you owe is $412.20 ($2061 x 20% = 
$412.20). Therefore, we decided that the Plan does not have to waive the coinsurance for a ferric derisomaltose 
injection provided on August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on May 23,
2022.

You asked the Plan to pay for the Guardant360 testing. You say that this testing is a payable service. The Plan
denied your request. The Plan says while the provider did bill with valid DEX Z-Code ZB1CW, the procedure
code 81479 billed was not listed as a recommended code. Maximus overturned the Plan's denial. The Plan
requested a reopening and stated that Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue,
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the
coverage status is listed in the DEXTM Diagnostics Exchange.

We looked at the file and Medicare rules. Review of the claim does not show that the correct unique identifier
was reported. The Z-code on the claim is not listed as valid for the CPT code billed. Based on this information,
we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we
decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on May 23,
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88348, 88313, 88346, 88350, and 88305 
billed for date of service June 28, 2023. 
 You asked the Plan to pay for procedure codes 88348, 88313, 88346, 88350, and 88305. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88348, 88313, 88346, 
88350, and 88305. This means there is both a professional and technical component for the CPT codes. In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT codes 
88348, 88313, 88346, 88350, and 88305. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88348, 88313, 88346, 88350, and 88305 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88348, 88313, 88346, 88350, and 88305 billed for date 
of service June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical examination and evaluation (92014) provided on 
September 18, 2023. 
 
You asked the Plan to pay for the medical examination and evaluation. You say that you were under the 
impression that you were just getting a yearly routine exam. You also say that you were in and out in a short 
amount of time, and no one said it was anything special or mentioned a copay. The Plan denied your request. 
The Plan says the services rendered were for a medical eye exam. The Plan also says that it was a one year 
follow up from cataract surgery. 
 
 
 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. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you were billed for a medical eye 
exam (92014), and not a routine exam. Based on this information, we decided that the Plan's rules for coverage 
of the medical examination and evaluation have not been met. Therefore, we decided that the Plan does not 
have to pay for the medical examination and evaluation (92014) provided on September 18, 2023.