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

 
We decided that the Plan does not have to waive the copayment for the skilled nursing services provided from 
March 1, 2020, to March 31, 2020. 
 
You asked the Plan to waive the copayment for the skilled nursing services. You say that you were held in lock 
down at the facility from March 16, 2020, to March 31, 2020 due to the COVID-19 crisis. The Plan denied 
your request. The Plan says the copayment amount that you are being charged is correct. 
 
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 $0 
copay per day for days 1 to 20 and a $178 copay per day for days 21 to 100 for Skilled nursing facility (SNF) 
care. This SNF stay previously had 9 days applied to it in February 2020. This portion of the SNF stay lasted 
31 days, which are days 10 to 40 of the stay, resulting in a copayment amount of $3,560. 
 
You have been asked to pay a $0 copay per day for days 1 to 20 and a $178 copay per day for days 21 to 100 
for the skilled nursing services. the skilled nursing services falls within the Skilled nursing facility (SNF) 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 for the skilled nursing services 
provided from March 1, 2020, to March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 17, 2020, by an OON 
provider. 
 
You asked the Plan to pay for an eye examination. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
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 medical services provided on June 17, 2020, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on August 24, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that this was a cancer screening and you 
disagree with the charges. 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 $55 
copayment for X-rays. 
 
The medical records show that you received an X-ray on August 24, 2020.  Therefore, you are responsible to 
pay the allowed amount of $20.74, which is less than the $55 copayment.  
 
You have been asked to pay $20.74 for an X-ray. An X-ray falls within the outpatient diagnostic tests and 
therapeutic services 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 copayment for 
an X-ray provided on August 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve assistant at surgery services provided on April 30, 2020. 
 
You asked the Plan to pre-approve the assistant at surgery services. You say that the primary surgeon felt that 
the assistant surgery services were in the best interest of the enrollee. You say that you had no choice and could 
not deny services to the enrollee. The Plan denied your request. The Plan says services of an assistant surgeon, 
co-surgeon, or surgical team are not covered for the procedures performed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 
15940 and 15931. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. 
This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid. Based upon this information, we find that Medicare coverage criteria for the assistant at surgery services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve assistant at surgery 
services provided on April 30, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to provide coverage for Udenyca for the enrollee.
You asked the Plan to provide coverage for Udenyca. You say that this drug is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen stating Maximus applied the incorrect coverage criteria.
Our Medical Director reviewed the case file and the reopen request. Our Medical Director says that the Plan is
correct in this case. The regimen for which Udenyca has been requested (Enfortumab Vedotin plus
Pambrolizumab) is not supported in the compendia for treatment of the enrollee's condition. Consequently,
Udenyca (Pegfilgrastim-cbqy) would not be considered medically reasonable and necessary for the enrollee in
this case. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare
rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met.
Therefore, we decided that the Plan does not have to provide coverage for Udenyca for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery and an inpatient 
hospital stay provided by a participating provider on April 27, 2020, to May 5, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery and an inpatient hospital stay. You say 
that you already met your out-of-pocket maximum The Plan denied your request. The Plan says the correct 
copayments have 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 $295 
copayment for outpatient surgery/in-network/outpatient hospital and a $345 copayment per day for days 1-5. 
There is a $0 copayment for additional days for inpatient hospital care/in-network.  
 
You have been asked to pay $241.35 which is less than your copayment amount of $295 for an outpatient 
surgery and a $345 copayment per day for days 1-5 for an inpatient hospital stay. The amount you are being 
asked to pay for the inpatient stay is $1,725 ($345 x 5 days = $1,725). The total amount you are being asked to 
pay is $1,966.35 ($1,725 + $241.35 = $1,966.35). An outpatient surgery falls within the outpatient surgery/in-
network/outpatient hospital benefit category. An inpatient hospital stay falls within the inpatient hospital 
care/in-network 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 outpatient surgery 
and an inpatient hospital stay provided by a participating provider on April 27, 2020, to May 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says the type of bill code submitted on the claim is not correct. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the type of bill codes submitted is not 
correct. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does 
not have to pay for home health services provided to the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee from March 4, 
2020, to March 30, 2020. 
 
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 Medicare only covers services directly related to manual manipulation. All other 
services are denied as non-covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided to the enrollee from March 4, 2020, to March 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mammography (77065) provided on May 11, 2020. 
 
You asked the Plan to pay for mammography. You say that this was medically necessary. The Plan denied your 
request. The Plan says the billed units exceed the MUE for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 77065 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of mammography have not been met. Therefore, 
we decided that the Plan does not have to pay for mammography (77065) provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (93297, 93296, 93295) provided April 2, 
2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider 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. No medical records were provided to the plan. Without clinical 
documentation, the claim cannot be supported. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (93297, 93296, 93295) provided April 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on August 4, 
2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that these lab services were done as 
part of your annual physical, so you shouldn't have to pay a copayment. The Plan denied your request. The Plan 
says you were charged this copayment 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 lab services.  
 
You have been asked to pay a $10 copayment for the lab services. Annual physical exams and wellness visits 
do not include lab services.  The services covered as part of these exams are explained on pages 65 and 66 of 
your Evidence of Coverage and neither of them includes lab services. 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 lab services you received on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 13, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on April 15, 2020. 
 
You asked the Plan to pay for a back brace. You say that this is supported by the documentation. The Plan 
denied your request. The Plan says these is not a proof of delivery for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the item provided in this case. The item at issue is not 
included on the submitted delivery invoice. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a back 
brace (L0650) provided on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 14, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (Q5001, G0299, G0156) provided 
April 6, 2020 to April 9, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was not filed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes Q5001, G0299, & G0156 are not supported. Specifically, the admit date on the claim 
did not match the date on the HIPPS Code, G-Code, and Q-Code. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services (Q5001, G0299, G0156) provided April 6, 2020 to April 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray you had on August 4, 2020. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you shouldn't have to pay a copayment 
for this x-ray. The Plan denied your request. The Plan says you were charged this copayment 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 x-rays.  
 
You have been asked to pay a $10 copayment for the x-ray. 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 x-ray you had on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on August 4, 
2020. 
 
You asked the Plan to pay for the dental service. You say that this service should have been covered. You also 
say that had you known it would not be covered, you would not have allowed for them to do the x-rays only did 
the x-rays on the last visit. The Plan denied your request. The Plan says 1 complete series of x-rays is a covered 
benefit once every 5 years. The Plan says that the frequency limit for this service has been exceeded. 
 
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 frequency limit of 1 complete 
series of x-rays every 5 years has been exceeded. The record shows that the Plan paid for a complete series of 
x-rays that you received on May 5, 2017, less than 5 years ago. Therefore, we decided that the Plan does not 
have to pay for the complete series of x-rays (D0210) provided on August 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
30, 2019. 
 
You asked the Plan to pay for the physician services. You say that the claim was originally denied because the 
enrollee was in hospice. You say that hospice denied the claim stating the visit was not under hospice. You say 
that the claim was resubmitted with condition code 7 and was denied again stating hospice should be billed. 
The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 the subsequent nursing facility care provided on September 
30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you feel more secure with a scooter. The Plan 
denied your request. The Plan says your current power wheelchair is in good condition, and used when needed. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair that is still in good condition. Your power wheelchair serves 
the same purpose as a power scooter. Therefore, we decided that the Plan does not have to pre-approve a power 
scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite (D2393). 
 
You asked the Plan to pre-approve the resin-based composite. You say that this service should be covered 
under the non-routine services. The Plan denied your request. The Plan says this service 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 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 pre-approve a 
resin-based composite (D2393).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has received Prolia injections for the past 
two years. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 
Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.