Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) and an ankle-foot orthosis 
(L1971) provided to the enrollee on March 20, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis 
(L3916) and an ankle-foot orthosis (L1971) provided to the enrollee on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections of pembrolizumab provided 
from March 9, 2020, to May 11, 2020. 
 
You asked the Plan to waive the coinsurance for injections. You say that being charged these amounts would 
cause a financial hardship for you. The Plan denied your request. The Plan says the coinsurance amounts you 
are being charged are 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 20% 
coinsurance for in-network Part B drug injections. The allowed amounts of these injections total $30,108, 
however you have only been asked to pay $4,294.84, which is less than 20% coinsurance. 
 
You have been asked to pay less than 20% coinsurance for injections. Injections fall within the Medicare Part B 
Prescription Drugs 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 injections of 
pembrolizumab provided from March 9, 2020, to May 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Allomap testing rendered on July 1, 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 must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee underwent a heart transplant in 2018. No medical records were provided for review. There is no evidence to support that the testing was reasonable or medically necessary to diagnose, treat or otherwise manage the enrollee's condition(s).
We looked at this physician's review, the file, and Medicare rules. 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 Allomap testing rendered on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 30, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the treating provider is a non-participating 
provider. The Plan also says that the service 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 medical services provided on April 30, 2020 
by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from April 1, 
2020 to April 30, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim was not submitted with the appropriate "Q" codes. 
 
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 claim submitted is lacking the 
required codes as stated above. 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 from April 1, 2020 
to April 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
24, 2019 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that it is your understanding that 
when a provider is called to see an enrollee during their nursing home stay, the services would be covered by 
Medicare. You also say that if any authorization is needed, the nursing home would be responsible for 
obtaining the authorization. The Plan denied your request. The Plan says the services were rendered by a non-
contracted provider. The Plan also says that the services were not authorized, and the provider did not contact 
the Plan for 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 
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 subsequent nursing facility care provided on 
September 24, 2019 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 23, 2018. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the claim was submitted outside of the timely filing limit of 365 days. 
 
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 services was not filed until February 21, 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 services provided on December 23, 2018.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 13, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by the provider. The provider is a contract provider. The 
file does not show that the plan provided notice that the laboratory services would not be covered. Under 
Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided 
that the Plan has to pay for the laboratory services provided on December 13, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for optiwave refractive analysis (66999) provided from January 
9, 2020 to January 16, 2020. 
 
You asked the Plan to pay for optiwave refractive analysis. You say that this was required for your cataract 
surgery. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that refractive procedures are not covered even when done 
in connection with otherwise covered diagnosis or treatment of illness or injury. 
 
The services you asked the Plan to pay for is a refractive procedure. Therefore, we decided that the Plan does 
not have to pay for optiwave refractive analysis (66999) provided from January 9, 2020 to January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $10.52 copayment charged for specialist services provided. 
 
You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan 
denied your request. The Plan says the claim we received from your provider was processed correctly 
according to your plan benefits.  According to your Evidence of Coverage on page 74-75, in-network 
outpatient diagnostic test rendered at a specialist office will have a $30 copayment. However, the remaining 
amount after the Plan paid the allowable was less than $30. Your member responsibility is the remaining 
portion of $10.51, which is less than your normal copayment.  
 
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 $30 
copayment for specialist. You are being charged less than the normal copayment amount. 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 $10.52 copayment charged for specialist services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 21, 2019 by an OON 
provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit and services. You say that at any given time 
you may be called to evaluate the enrollee, and/or recommend treatment, per the facility's request. You also say 
that the services were medically necessary. The Plan denied your request. The Plan says the treating provider is 
not a network provider. The Plan also says that the services were not 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 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 May 21, 2019 by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis and an addition provided April 30, 2020. 
 
You asked the Plan to pay for the knee orthosis and addition. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an 
established relationship between the member and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 knee orthosis and addition. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the member has not had recent injury to or a surgical procedure on the 
knee(s). The member is noted to be ambulatory. The documentation is not convincing that the member has 
instability on an objective properly performed physical exam by a trained physician or medical practitioner. It 
is unclear how a pivot shift test and Cabot's test could have been properly performed alone by the member as 
this was a telemedicine visit. The documentation does not support sufficient evidence of an established 
relationship between the member and the ordering physician. 
 
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 knee orthosis and addition have not been met. Therefore, we decided that 
the Plan does not have to pay for a knee orthosis and an addition provided April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an X-Ray examination and office visit 
provided on June 9, 2020. 
 
You asked the Plan to waive the copayments for X-Ray exam and office visit. You say that you were told that 
this was a post-operative visit and you would not be charged. The Plan denied your request. The Plan says the 
copayment amounts you are being charged are 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 $20 
copayment for X-Ray and $50 copayment for specialist office visit. For the office visit you have only been 
asked to pay $30, which is less than the $50 copayment for a specialist office visit. Your total copayment 
obligation is therefore $50. 
 
You have been asked to pay $20 copayment for X-Ray and less than $50 copayment for office visit. X-Ray 
exam and office visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and 
"Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 X-Ray examination and office visit provided on June 9, 2020.   
 
 
Your complaint regarding receiving inaccurate information about the cost-share for these services is considered 
to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please 
contact the Plan for more information about your grievance.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 by you on May 
25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency department visit (92285) provided April 4, 2020.
You asked the Plan to waive the copayment for emergency department visit. You say that you are on social security benefits and unable to afford to pay the outstanding balance. The visit was needed due to being in pain and all services were either closed or not giving assistance. The Plan denied your request. The Plan says this claim has processed correctly per the Evidence of Coverage.
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 $90 emergency room copayment. You have been asked to pay $90 for the emergency department visit. The emergency department visit 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 for emergency department visit (92285) provided April 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment fora physician office visit (99213) on April 5, 2020.You asked the Plan to waive the copayment fora physician office visit. You say that this was not a specialist office visit.The Plan denied your request. The Plan says that the correct copayment was applied.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 enrollees must pay a $0 copayment for primary care provider doctor visits. The Plan says you must pay a $30 copayment for a physician office visit. The Plan acknowledges, however, that the provider at issue is not a specialist doctor. Based on the Plan contract, you cannot be asked to pay more than a $0 copayment for a primary care provider office visit.Therefore, we decided that the Plan has to waive the copayment fora physician officevisit (99213) on April 5, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient radiology services provided by the out of 
network provider. 
 
You asked the Plan to pay for the outpatient radiology services. You say that the services should be covered. 
The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, 
covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also 
says that during the election, fee-for-service Medicare also covers attending physician services and all care 
unrelated to the terminal illness until the first day of the month following the month in which hospice was 
revoked or discharged. 
 
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 outpatient radiology services provided  by the out of
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
the Plan does not pay for non-emergency visits with non-contracted providers when contracted providers are 
available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTecentriq.You asked the Plan to pre-approvethe Tecentriq. You say that you would like reconsideration because this drug is medically necessary.The Plandenied your request. The Plan says there is no indication for or compendia based treatment for the use of Tecentriq in extra pulmonary small cell poorly differentiated neuroendocrine cancer.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Tecentriq. Our reviewer says that Tecentriq is not FDA approved for the requested use and Tecentriq is not supported for use in rectal small cell cancer in any of the CMS approved compendia. Our physician reviewer found the use is not listed as not indicated, not supported, or not recommended for the requested use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the Tecentriq have not been met.Therefore, we decided that the Plan does not have to pre-approveTecentriq.