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

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on February 18, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $290 
copayment for ambulance services.  
 
You have been asked to pay a $290 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip 
provided by a participating provider on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient home visit (99350) provided on April 
10, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient home visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 established patient home visit (99350) 
provided on April 10, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG procedure (93000) performed on 
June 4, 2020. 
 
You asked the Plan to waive the copayment for an EKG. You say that this procedure was not performed on 
June 4, 2020. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $20 
copayment for Medicare-covered non-radiological diagnostic services.  
 
Medical records supplied by the provider support that an EKG was performed on June 4, 2020. You have 
therefore been asked to pay a $13.95 copayment for an EKG. An EKG falls within the "Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay 
less than or equal to 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 an EKG procedure (93000) performed on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen supplies (E1390) provided March 
18, 2019 to January 18, 2020. 
 
You asked the Plan to waive the coinsurance for the oxygen supplies. You say that you were told the oxygen 
would be fully covered. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 10% 
coinsurance for Medicare covered equipment and supplies.  
 
You have been asked to pay a 10% coinsurance for the oxygen supplies. The oxygen supplies fall within the 
Medicare covered equipment and 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for oxygen supplies (E1390) provided March 18, 2019 to January 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the battery back-up. 
 
You asked the Plan to pre-approve the battery back-up. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this type of battery backup equipment is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. This type of battery backup equipment is not covered by Medicare. Therefore, we decided 
that the Plan does not have to pre-approve the battery back-up.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
physician's treatment plan to walk 30 minutes daily does not indicate the enrollee has a mobility dysfunction 
and the physician's notes do not indicate the enrollee has a personal mobility deficit that impairs participation in 
 
 
MRADLs or is unable to be alleviated with a manual wheelchair. The physician's notes do not support that the 
enrollee has a mobility limitation due to a neurological condition/myopathy/congenital skeletal deformity. The 
documentation is inconsistent on the enrollee's ambulatory function. The documentation indicates the enrollee 
has no myalgia, back pain, joint swelling, arthralgia, gait problem, weakness. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 heavy duty power wheelchair for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were transferred to the hospital by a 
separate company. 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 May 25, 2020. 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 services provided on May 25, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen concentrators (E1390 and E1392) 
from January 12 to July 25, 2020. 
 
You asked the Plan to waive the coinsurance for oxygen concentrators. You say that you have a hard time 
paying these copayments. The Plan denied your request. The Plan says the correct copayments were applied. 
 
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 10% 
coinsurance for covered durable medical equipment and related supplies.  
 
You have been asked to pay $4.11 per month, or 10% of the Plan-allowed amount of $41.05, and $13.50 per 
month, or 10% of the Plan-allowed amount of $135.00, for oxygen concentrators. Oxygen concentrators fall 
within the "Durable medical equipment (DME) 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for oxygen concentrators (E1390 and E1392) from January 12 to July 
25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the care could be received in another setting, such as a skilled nursing 
facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be improving but require additional acute care services for less than 25 
days. This can be safely completed at the current facility. You do not require services at the LTACH that are 
not already available at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to a lower level of care may be considered with more time at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided. 
 
You asked the Plan to pay for the limited oral evaluation and intraoral x-ray. You say that the x-ray was taken 
after you fell and they needed to evaluate the tooth. You say that these should be covered. The Plan denied 
your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 
limited oral evaluation and intraoral x-ray provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fabricated ankle-foot orthosis (AFO) coded as 
L1940 with related additions described by codes L2820 and L2330. 
 
You asked the Plan to pre-approve the custom AFO. You say that these braces are required to treat the 
enrollee's left foot pain. The Plan denied your request. The Plan says the enrollee does not have any condition 
for which bilateral bracing is needed. 
 
The Plan follows Medicare rules. Medicare rules say that AFOs are covered for ambulatory enrollees who meet 
the above criteria.  
 
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 custom AFO. Our reviewer says 
that the requested AFO and components are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a female who presented to podiatry with a complaint of left foot 
pain. Based on the medical records provided, there is no documentation that the criteria for the custom-made 
ankle-foot orthoses with the requested additions are met. The provided records do not document a condition for 
which stabilization is required or provide details as to why prefabricated orthoses are not appropriate. No 
objective measure of weakness or deformity is detailed. There is no detailed documentation of a neurological, 
circulatory, or orthopedic condition that requires custom fabricating. 
 
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 custom AFO have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a custom-fabricated ankle-foot orthosis (AFO) coded as L1940 with related additions 
described by codes L2820 and L2330.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a finger splint (29130) on March 2, 2020. 
 
You asked the Plan to pay for the application of a finger splint. You say that this is supported in the records. 
The Plan denied your request. The Plan says this is not supported for the billed date of service. 
 
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 29130 is application of finger splint; static. 
 
We find that CPT code 29130 is not supported in the medical record. Specifically, the records indicate that this 
service was performed on March 3, 2020, but it was billed for March 2, 2020. Based on this information, we 
decided that Medicare rules for coverage of the application of a finger splint have not been met. Therefore, we 
decided that the Plan does not have to pay for the application of a finger splint (29130) on March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the 
enrollee from February 10, 2020, to May 5, 2020. 
 
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an invalid procedure code for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the therapy have 
not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS 
S9328) provided to the enrollee from February 10, 2020, to May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings to 
prevent blood clots. The Plan denied your request. The Plan says you do not have a qualifying wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
 
 
 
 
 
 
 
 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health services provided on March 12, 
2020, to March 30, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient mental health services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained for these non-emergent services rendered by a non-participating provider in a non-participating 
facility. 
 
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 has network providers 
available who can provide 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 inpatient mental health services provided on 
March 12, 2020, to March 30, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forGuardant360 molecular pathology genomic profiling provided to the enrollee on June 23, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for breast cancer.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forGuardant360 molecular pathology genomic profiling provided to the enrollee on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services rendered. 
 
You asked the Plan to waive the copayment for these services. You say that the services were for an annual 
physical and should have no copayment. The Plan denied your request. The Plan says the copayment was 
applied 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 $10 
copayment for Medicare-covered laboratory tests.  
 
Review of the file shows that you received laboratory services. These services fall outside of 
the scope of an annual preventive exam. You have been asked to pay a $10 copayment for these services. These 
services fall within the Medicare-covered laboratory tests 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 laboratory services rendered.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with an 
appropriate HIPPS code. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid HIPPS code. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on July 24, 2020.You asked the Plan to waive the copayment foremergency care. You say that you disagree with the charges because the emergency room did not diagnose your blood clots.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 care. You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care 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 foremergency care provided on July 24, 2020.Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.