Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital services provided from 
August 27, 2020, and August 31, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you should not owe 
anything for the visits. 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 10% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received outpatient hospital services on August 27, 2020. The total allowed amount is $118.96 and 10% of 
that is $11.90.  
 
You received outpatient hospital services on August 31, 2020. The total allowed amount is $118.96 and 10% of 
that is $11.90. 
 
The total amount you owe is: $23.80.  
 
You have been asked to pay the total coinsurance amount of $23.80 for outpatient hospital services. Outpatient 
hospital services fall 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 coinsurance for 
outpatient hospital services provided from August 27, 2020, and August 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on July 3, 2020 
by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the treating physician depends 
upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance 
company. You also say that the treating physician provided medically necessary services to the enrollee in 
good faith. The Plan denied your request. The Plan says the treating provider is a non-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 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 domiciliary or rest home visit provided on July 
3, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 had network providers 
available who could have provided 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 the enrollee by an out-of-
network provider on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 Factor V Leiden testing for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is nothing in the record to indicate the enrollee has an unusual situation which 
would preclude him from standard of care medical practices or warrant exception to Medicare rules for 
coverage of this test. 
 
The Plan must follow Medicare rules. The rules say that Factor V Leiden testing is only covered for pregnant 
patients. 
 
You do not qualify for this testing. 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 pre-approve F5 Factor V 
Leiden testing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies (A4221, A4222) provided on May 2, 2019, 
through May 28, 2019. 
 
You asked the Plan to pay for the infusion supplies. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says these services are inclusive under the services 
approved and paid to the attending oncologist. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare's payment for the administration of the 
drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infusion supplies have not been met. Specifically, payment for this equipment is included in the 
payment for the administration of the drug. Therefore, we decided that the Plan does not have to pay for 
infusion supplies (A4221, A4222) provided on May 2, 2019, through May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on August 14, 2019. 
 
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 vision services was not filed until September 16, 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 vision services provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
services coded 95940 provided on December 9, 2019. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring services. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are not supported by the documentation. 
 
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 95940 is continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 95940 is not supported in the medical record. Specifically, this code has a professional 
component/technical component indicator of 3. This code was billed with modifier TC. Modifiers 26 and TC 
cannot be used with these codes. Based on this information, we decided that Medicare rules for coverage of the 
continuous intraoperative neurophysiology monitoring services have not been met. Therefore, we decided that 
the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring services coded 
95940 provided on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided 
from August 18, 2020, to August 21, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. You say that you disagree with 
the charges because you feel the services could have been done as an office visit. 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 $250 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $250 copayment for outpatient hospital observation. Outpatient hospital 
observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from August 18, 2020, to August 21, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lidocaine (J2001) and triamcinolone acetonide injections 
(J3301) provided on May 21, 2020. 
 
You asked the Plan to pay for lidocaine and triamcinolone acetonide injections. You say that these codes are 
supported in the records. The Plan denied your request. The Plan says these codes are bundled into other codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Services with status indicator N are paid under 
the OPPS, but their payment is packaged into payment for a separately paid service. 
 
We find that CPT code J2001 and J3301 is not supported in the medical record. Specifically, these codes have a 
status indicator of N and their payment is packaged into payment for a separately paid service. Based on this 
information, we decided that Medicare rules for coverage of lidocaine and triamcinolone acetonide injections 
have not been met. Therefore, we decided that the Plan does not have to pay for lidocaine (J2001) and 
triamcinolone acetonide injections (J3301) provided on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits provided from September 2, 
2020, to September 17, 2020. 
 
You asked the Plan to waive the copayments for office visits. You say that you were inadvertently enrolled in 
this plan, and are requesting reimbursement for these amounts you were forced to pay that you would not have 
been charged under your previous plan. The Plan denied your request. The Plan says the copayment amounts 
you are being charged are correct. The Plan also says that these amounts should be paid for by your Medicaid 
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 $40 
copayment for each specialist visit. There were 2 visits, resulting in a total copayment amount of $80. 
 
You have been asked to pay $40 copayment for each office visit. Office visits 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 copayments for office visits provided from September 2, 2020, to September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on September 28, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that these lab tests were ordered by the referring provider. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is also out-of-network. 
 
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 had network providers 
available who could have provided 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 lab work provided on September 28, 2020 by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires provided on September 19, 2020. 
 
You asked the Plan to pay for the lead wires. You say that code A4557 can be billed separately. The Plan 
denied your request. The Plan says records supporting the necessity of additional lead wires were not 
submitted. 
 
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 looked at the file and the rules. The records show that a TENS device was provided within the last 12 
months. We find that CPT code A4557 is not supported in the medical record. Specifically, there are 
insufficient records to show that the replacement wires were necessary. 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 lead wires provided on September 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 13 additional extractions provided from September 16, 
2020, to October 14, 2020. 
 
You asked the Plan to pay for the extractions. You say that your teeth were breaking off at the gum, and you 
were unable to eat properly. The Plan denied your request. The Plan says benefits for this service had been 
satisfied and the frequency limitation had 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, extractions are limited to two 
procedures per calendar year. The record shows that you received eight extractions on September 16, 2020, two 
of which were covered by the Plan, and your extractions benefit had been exhausted. Therefore, we decided 
that the Plan does not have to pay for the 13 additional extractions provided from September 16, 2020, to 
October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with multiple power options. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says it is not medically necessary to control the three requested power options through 
the joystick/drive interface. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found you have the 
cognition to operate the PMD but the documentation does not reveal this request is medically necessary. The 
WC face to face is for a K0861 Group 3 power wheelchair. The documentation does not reveal evidence of a 
myopathy, myopathy, or congenital skeletal deformity that needs a Group 3 power wheelchair. There is no 
evidence that you are unable to transfer from wheelchair to bed or use intermittent catheterization, has 
increased tone or spasticity, or are unable to weight shift. The E2377 Expandable Controller and E2313 
Expandable Controller Harness are not medically necessary per Local Coverage Article: Wheelchair 
Options/Accessories - Policy Article (A52504). The documentation does not reveal that you require other types 
of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head 
control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) You do not need to operate 
3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control 
devices), other electronic devices (e.g., control of an augmentative speech device or computer through the 
chair's drive control), or an attendant control. Your function and strength in the upper extremities should be 
sufficient to control any power options through their own switches. As the requested Group 3 power wheelchair 
is not medically necessary, the E1028 and the positioning back cushion/skin protection cushion are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair with multiple power options.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D, Hemoglobin and Thyroid stimulating 
hormone testing (82306, 83036 and 84443) provided on June 4, 2020. 
 
You asked the Plan to pay for the testing. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says these services are not Medicare benefits for the 
diagnosis listed. 
 
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, the testing, 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 
Vitamin D, Hemoglobin and Thyroid stimulating hormone testing (82306, 83036 and 84443) provided on June 
4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services with CPT code 64718 
provided on July 10, 2020. 
 
You asked the Plan to pay for the assistant at surgery services. You say that the surgical assistant services were 
medically necessary. The Plan denied your request. The Plan says the surgical assistant services were not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for CPT code 64718. The 
Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.  
 
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 assistant at surgery services. Our 
reviewer says that the surgical assistant services were not medically necessary. Our physician reviewer found 
the enrollee underwent a left open carpal tunnel release. The procedure is listed with "0" indicating an assistant 
surgeon is not indicated for this procedure. There were no documented complications (and/or increased risks 
and/or complexity) noted on the operative note. The complexity of the procedure (left open carpal tunnel 
release) does not support the need for an assistant surgeon. Therefore, the surgical assistant was not medically 
reasonable and necessary for the enrollee in this case. 
 
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 assistant at surgery services have not been met. Therefore, we decided that 
the Plan does not have to pay for the assistant at surgery services with CPT code 64718 provided on July 10, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services you received from July 15, 2019, to 
July 23, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services you received from July 15, 2019, to July 23, 
2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on February 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 the claim was not filed timely. 
 
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 these services was not filed until November 3, 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 rendered on February 12, 2019.