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

 
We decided that the Plan does not have to waive the copayments for an electrocardiogram (EKG) and office 
visit (93000, 99213) provided February 25, 2020. 
 
You asked the Plan to waive the copayments for the EKG and office visit. You say that the copayments should 
be waived because this was a follow up visit. 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 a $75 
copayment for diagnostic testing and a $50 copayment for specialist office visits.  
 
You have been asked to pay the allowable amount of $20.86 for the EKG and a $50 copayment for the 
specialist office visit. In this case the allowable amount of $20.86 is less than the $75 copayment noted in the 
plan contract for the EKG. 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 copayments for an electrocardiogram 
(EKG) and office visit (93000, 99213) provided February 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional mileage from the air ambulance service 
provided on December 15, 2019. 
 
You asked the Plan to pay for the additional mileage. You say that the transport was medically necessary so the 
full mileage should be paid. The Plan denied your request. The Plan says the provider was paid air ambulance 
transport rates for mileage to the closest appropriate facility, 50 miles. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services to the nearest 
appropriate facility.  
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the additional mileage charge have not been met. Therefore, we decided that the Plan does not 
have to pay for the additional mileage from the air ambulance service provided on December 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS emergency ambulance service (A0429) and ground 
mileage (A0425) provided December 1, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that you would like to appeal this because 
according to the nursing home the enrollee fell and hit her head and needed to be examined at the hospital. The 
Plan denied your request. The Plan says by adding the GY modifier, the ambulance company has designated 
this trip as a non-billable 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, by adding the GY modifier, the ambulance company has designated this trip as a non-billable 
service. The GY modifier indicates that this service is not eligible for payment. A new claim form would need 
to be submitted. Based on this information, we decided that Medicare rules for coverage of the ambulance 
service have not been met. Therefore, we decided that the Plan does not have to pay for BLS emergency 
ambulance service (A0429) and ground mileage (A0425) provided December 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on October 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. The rules say that critical care is not a service that is paid on a 'shift' 
basis or a 'per day' basis. Critical care service is paid on a time-based service provided on an hourly or fraction 
of an hour basis. For this reason, the documentation provided by the physician must include the amount of time 
in hours and minutes that is spent on providing critical care service. In this case, there is no evidence in the 
medical documentation to show the total time spent delivering critical care to the enrollee.  

Therefore, we decided that the Plan does not have to pay for the critical care services provided on October 12, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 30, 2019. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the 
provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare policies.  
 
The physician notes do not mention or support medical necessity for the orthosis. Therefore, we decided that 
the Plan does not have to pay for the lumbar-sacral orthosis provided on August 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided from August 21, 2019 
to November 21, 2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized by the Plan before the 
services are provided. 
 
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 from August 21, 2019 to 
November 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on February 3, 2019. 
 
You asked the Plan to pay for the emergency room services. You say that it is not felt that missing the deadline 
justifies denial of payment. The Plan denied your request. The Plan says Medicare claims must be submitted 
within one year. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency room services was not filed until April 1, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the emergency room services provided on February 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on February 21, 
2020. 
 
You asked the Plan to waive the deductible for the office visit. You say that you did not choose a plan that had 
a deductible. You say you would like the Plan to pay the member responsibility. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible that applies towards in-network office visits.  
 
The office visit you asked the Plan to waive the deductible for falls within the 'Physician/Practitioner services, 
including doctor's office visits' benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $300 deductible that applies towards in-network office visits. This cost sharing is a 
contractual obligation that had not been met at the time the office visit was received on February 21, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on 
February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (67028, J0178) provided on February 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of codes 67028 and J0178 is not supported by the records provided. Our coding reviewer found that the 
provider submitted a Single Claim Reconsideration/Corrected Claim Request Form, documenting "Medical 
documentation submitted clearly states OD injection in exam notes with DOS but injection operative note has 
been updated to reflect patient name, injection site, and date of service". The procedure note submitted has a 
handwritten patient name, date of service and right eye injected. However, per Medicare guidelines, all changes 
to a medical record must clearly indicate the date and author of the amendments, corrections or addenda. The 
procedure report does not clarify date and author of the amendments, therefore this billed services cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (67028, J0178) provided on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 20, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 
physician's 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 January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99306) provided on April 20, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for OON nursing facility care. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was 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 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 nursing facility care (99306) provided on April 
20, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you were visiting your son when you fell. 
You went into the bathroom and when you came out, there were emergency responders there. You stated that 
you refused medical care and did not get in the ambulance. You say that you signed a release form and now 
you have received a bill for the services. You stated that the services should be covered, and they are a 
financial difficulty for you. You asked the Plan to reconsider providing coverage. 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 April 21, 2019. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee from January 3, 
2020, to January 4, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the records do not 
show that the provider performed these services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The documentation submitted does not show that the lab services in 
question were provided by this provider on the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided to the enrollee from January 3, 2020, to January 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided from May 1, 2019 to February 
5, 2020. 
 
You asked the Plan to pay for the laboratory 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 and the ordering provider are not network providers with the Plan. The Plan 
did not pre-approve the laboratory 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 laboratory services provided from May 1, 
2019 to February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hernioplasty provided on March 10, 2020. 
 
You asked the Plan to waive the copayment for a hernioplasty. You say that the surgery was due to a previous 
surgical procedure being unsuccessful. You feel that you should not owe a second copayment. 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $200 copayment for a hernioplasty. A hernioplasty falls within the outpatient 
surgery, including 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 hernioplasty provided on March 10, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite of one surface and resin-based 
composite of two surfaces provided on January 23, 2020. 
 
You asked the Plan to pay for the resin-based composites. You say that you were not aware that your 
comprehensive dental coverage did not go into effect until February 1, 2020. You also say that your dentist did 
not verify this, and told you the services would be covered. The Plan denied your request. The Plan says these 
services were not a covered benefit. The Plan also says that your comprehensive dental coverage did not 
become active until February 1, 2020. 
 
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 resin-
based composite of one surface and resin-based composite of two surfaces provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have stage 4 cancer and you lose 
control of your bowels without any advanced warnings. You say that you need the Plan to cover the supplies 
because there is no alternative for you, and you spend a lot of money on them. You asked the Plan to reconsider 
providing coverage for the requested supplies. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that finger stick testing has caused 
pain, cramping, loss of grip, and arthritis on both hands. The Plan denied your request. The Plan says the 
information submitted does not show you check your blood sugar four or more times a day or get insulin three 
or more times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Your medical record shows you are not insulin treated by injection 
three or more times a day so the Medicare coverage criteria for a CGM is not met. Based on this information, 
we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA Analysis with Myriad my Risk Hereditary 
Cancer Update Test. 
 
You asked the Plan to pre-approve BRCA genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA testing is only covered for certain indications. 
 
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 BRCA genetic testing. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found you have a family history of malignant neoplasm of digestive organs. You have 
no personal history of cancer. It is noted that your father had pancreatic and colon cancer. The documentation 
does not support that you have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for 
coverage of BRCA testing. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve BRCA Analysis with Myriad my Risk Hereditary Cancer Update Test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have weakness on your left side of your 
body and cannot stand for too long. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the POV, group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800NU). 
 
You asked the Plan to pay for the POV. You say that the POV is medically necessary. The Plan denied your 
request. The Plan says the POV 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 pay for the POV. Our physician reviewer found the 
documentation does not support that you in this case have a mobility limitation that significantly impairs your 
ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, 
feeding, dressing, grooming, and bathing in customary locations in the home. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have 
to pay for the POV, group 1 standard, patient weight capacity up to and including 300 pounds (K0800NU).