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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
additional transportation trips. You state that you did not use all of your trips and that someone else used them. 
The Plan denied your request. The Plan says you exhausted your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of fifty (50) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 51st trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on April 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on April 
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of platelet-rich plasma (PRP).

You asked the Plan to pre-approve platelet-rich plasma. You say that you believe this can help alleviate your pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because platelet-rich plasma is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that platelet-rich plasma is not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of platelet-rich plasma have not been met. Therefore, we decided that the Plan does not have to pre-approve use of platelet-rich plasma (PRP).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips, for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
additional transportation trips for the enrollee because the enrollee needs to continue their radiation and 
chemotherapy weekly. The Plan denied your request. The Plan says the enrollee exhausted their benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of fifty (50) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 51st trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips, for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on January 22, 
2020. 
 
You asked the Plan to pay for the assistant services. The Plan denied your request. The Plan says the codes are 
not eligible for assistant surgeon reimbursement. 
 
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 CPT codes33511, 33533, and 33508 have not been billed correctly. In this case, you billed 
assistant surgery services for the codes at issue, using modifier AS. The Medicare Fee Schedule Database 
contains a surgical indicator of 2 for these procedures. The rules say that modifier 80, 81 or 82 must also be 
billed when modifier AS is billed.  
Based on this information, we decided that Medicare rules for coverage of the assistant services have not been 
met. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services provided on 
January 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 19, 
2019. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment 
because this was part of your physical. 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 $295 
copayment for outpatient surgery and other services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $295 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery and other services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy provided on December 19, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 45380) provided on January 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 45380 is part 
of an edit pair with procedure code 45385. Procedure code 45385 is a column one code, and procedure code 
45380 is a column two code. Procedure code 45385 has been paid on this claim, which means that procedure 
code 45380 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the 
services (CPT 45380) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pleural drainage (32557), a biopsy (32405), and sedation services (99152) provided on February 26, 2020.
You asked the Plan to pay for pleural drainage, a biopsy, and sedation services. You say that these services were billed correctly. The Plan denied your request. The Plan says the submitted documentation was insufficient to verify these services.
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 CPT codes 32557, 32405, and 99152 is not supported in the medical record. Specifically, the submitted records do not include a detailed procedure note for these services. Without this information, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of pleural drainage, a biopsy, and sedation services have not been met. Therefore, we decided that the Plan does not have to pay for pleural drainage (32557), a biopsy (32405), and sedation services (99152) provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for specialist services provided from 
November 20, 2019 to December 17, 2019. 
 
You asked the Plan to waive the coinsurance for specialist services. You say that 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 20% 
coinsurance for physician/practitioner services, including doctor's office visits.  
 
You received specialist services from November 20, 2019 to December 17, 2019. Therefore, you are 
responsible to pay your share of the cost-sharing charges. Please see the chart below.  
 
Date of Service Service Code Allowed Amount Amount You Owe 
11/20/2019 37765 $675.81 $135.16 
12/11/2019 36471 $199.93 $39.99 
12/17/2019 36471 $199.93 $39.99 
 
The total amount you owe is: $215.14. 
 
You have been asked to pay the total coinsurance amount of $215.14 for specialist services. Specialist services 
fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided from November 20, 2019 to December 
17, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home hospice care services provided from April 29, 2019 
to July 24, 2019. 
 
You asked the Plan to pay for the home hospice care services. You say that the services were not hospice 
related. The Plan denied your request. The Plan says the service was rendered by a provider who is not under 
contract with the health plan, and is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. This provider is not eligible to receive Medicare payment. Based on 
this information, we decided that Medicare rules for coverage of the home healthcare services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home hospice care services provided from 
April 29, 2019 to July 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine and administration charge provided on June
12, 2019.
You asked the Plan to pay for the Tdap vaccine and administration charge. You say that you tried to obtain the
proper care so the Plan should waive the total amount that was applied towards your deductible. The Plan
denied your request. The Plan says the vaccine is not covered under your Medicare Part B benefit but is
covered under your pharmacy benefit and so it was applied to your deductible.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine.
Therefore, we decided that the Plan does not have to pay for the Tdap vaccine and administration charge
provided on June 12, 2019.
Benefits for the Tdap vaccine and administration charge were paid under your Medicare Part D benefit. Contact
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on August 21, 2019. 
 
You asked the Plan to pay for psychotherapy visit. You say that your provider rendered medically necessary 
service in good faith. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because no medical records were submitted to support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provide must submit to the Plan sufficient 
information to determine whether payment is due for a claim.  
 
We looked at the file and Medicare rules. No medical records were submitted to support the service billed. The 
Plan requested this information, but it was not provided. Without supporting records, you have not furnished to 
the Plan sufficient information to determine that payment is due for this claim as billed. Based on this 
information, we decided that Medicare rules for coverage of psychotherapy visit have not been met. Therefore, 
we decided that the Plan does not have to pay for a psychotherapy visit provided on August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on March 12, 2020 through March 
16, 2020. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says procedure 08Q8XZZ Repair Right Cornea, 
External Approach, is identified as a non-covered procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that there are some procedures for which Medicare 
does not provide reimbursement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital services have not been met. Specifically, per Medicare, diagnosis code 08Q8XZZ is 
always non-covered. Therefore, we decided that the Plan does not have to pay for hospital services provided on 
March 12, 2020 through March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel rendered on January 7, 2020. 
 
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 testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a CYP panel, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
CYP panel rendered on January 7, 2020.  
 
The Plan references Local Coverage Determination (LCD) L35062 in their review; however, this LCD is not 
valid for the state of CT where the testing was performed and was not used in the MAXIMUS review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography (99308) provided on December 13, 2019.
You asked the Plan to pay for the echocardiography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says with the information submitted, the Plan cannot determine how the member came to the servicing provider or whether the services are medically necessary.
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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the echocardiography have not been met. Specifically, there is insufficient documentation to determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not have to pay for echocardiography (99308) provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the continuous glucose monitor provided on February 27, 2020.
You asked the Plan to waive the cost share for the services provided. You say that you cannot afford the copay. The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for each Medicare-covered item for durable medical equipment. You have been asked to pay 20% of the cost for the glucose monitor. The item falls within the durable medical equipment 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 cost share for the continuous glucose monitor provided on February 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breathing capacity test (94010) performed 
on March 12, 2020. 
 
You asked the Plan to waive the copayment for a breathing capacity test. You say that you should not have a 
copayment for a primary-care physician visit. 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.  
 
You have been asked to pay a $20 copayment for a breathing capacity test. Even when performed at your 
primary-care physician's office, a breathing capacity test falls within the "Other outpatient diagnostic tests - 
Non-radiological diagnostic 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 a 
breathing capacity test (94010) performed on March 12, 2020.  
 
Your complaint about incorrect or misleading information provided to you by a representative of the Plan 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs provided on April 2, 2020.
You asked the Plan to pay for the services provided. You say that the charges are a hardship. The Plan denied your request. The Plan says a corrected claim is needed from the provider.
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 Plan requested an itemized claim from the provider to show what services were rendered. However, a valid claim was not provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drugs provided on April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denosumab injection and related services provided on 
January 21, 2020. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the billed charges. 
The Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 J0897 is injection, denosumab. The CPT Code Manual 
definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 
subcutaneous or intramuscular. We find that the billed codes are not supported in the medical record. The 
provided medical records do not show that the services at issue were performed on the date of service at issue.  
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the denosumab injection and related services provided on 
January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound examination of the heart 
performed at a hospital on January 27, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound examination of the heart performed at a hospital. 
You say that your copayment for an ultrasound should have been $20. 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 $250 
copayment for a hospital visit for outpatient surgery or procedure.  
 
You have been asked to pay a $250 copayment for an ultrasound examination of the heart performed at a 
hospital.  An ultrasound examination of the heart, when performed at a hospital, falls within the outpatient 
hospital 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 ultrasound 
examination of the heart performed at a hospital on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 12, 2019. 
 
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 procedure code 81479 is not covered. 
 
The Plan must follow Medicare rules. The rules say that the MammaPrint testing is billed with procedure code 
81521. 
 
We looked at the file and Medicare rules. The Plan approved billed code 81521. Billed code 81479 is not 
supported for this testing. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on August 12, 2019.