Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost for the blood draw. We decided that the Plan does not have to 
waive the cost for the laboratory test.  
  You asked the Plan to waive the cost for the blood draw and laboratory test. You say that this blood draw 
happened in the provider's office, and you should not have to pay the copayment. The Plan says that the $75 
copayment applied correctly. 
 
We decided that the Plan has to waive the cost for the blood draw.  
 
The Plan says you must pay $70.34 toward the blood draw as they considered it an outpatient diagnostic 
service. The blood draw is considered a physician service that is included as part of the office visit. Therefore, 
we decided that the Plan has to waive the cost for the blood draw.  
 
We also decided that the Plan does not have to waive the cost for the laboratory test. 
 
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 $75 for 
outpatient diagnostic tests. You have been asked to pay $4.66 for the laboratory test as that is the allowed 
amount for the service. Therefore, we decided that the Plan does not have to waive the cost for the laboratory 
test. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement services (11043) provided 
on October 25, 2021. 
 
You asked the Plan to waive the copayment for the debridement services. You say that this copayment should 
be waived. The Plan denied your request. The Plan says the copayment has processed correctly for the services 
at issue. 
 
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 Surgery.  
 
You have been asked to pay a $250 copayment for the debridement services. The services rendered fall within 
the Outpatient Surgery and Other Medical 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 the debridement 
services (11043) provided on October 25, 2021.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the lower extremity; 
without contrast material (73700). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that you have bilateral knee 
osteoarthritis with plans for a total knee arthroplasty procedure. There was a preservice request for a CT scan of 
the lower extremity; without contrast material for a robot assisted bi-lateral total knee replacement surgery. 
However, your x-rays could have been sufficient imaging to support and guide surgery as there was no 
abnormal atypical findings that needed follow-up with computed tomography due to a potential change of the 
surgical procedure. Also, there is insufficient support from high quality studies showing robotic-assistance for 
this procedure is superior in long-term health outcomes. Therefore, this request for a CT scan will be 
considered 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) of the lower extremity; without contrast material (73700).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetics (L5301, L5645, L5972, L5704, 
L5940, L5629, L8420, L5620, L5637, L5910, L8470, L5968, L5671, L5673, L8440) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve lower limb prosthetics. You say that you need a company that will come to 
you because you are unable to go to an office for prosthesis, and this provider is the only one that is able to 
service you. The Plan denied your request. The Plan says you must use network providers to get your medical 
care and services. The Plan also says they have confirmed that these services/items may be obtained with an in-
network supplier. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lower limb prosthetics (L5301, L5645, L5972, L5704, L5940, L5629, L8420, L5620, L5637, L5910, L8470, 
L5968, L5671, L5673, L8440) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $238.54 copayment for ambulance transportation on 
February 26, 2022. 
 
You asked the Plan to waive the $238.54 copayment for ambulance transportation on February 26, 2022. You 
say that this service has been covered in the past. The Plan denied your request. The Plan says you must pay a 
$238.54 copayment for ambulance services. 
 
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 per one-way trip for Ambulance Services.  
 
You have been asked to pay a $250 copayment for ambulance transportation. Ambulance transportation falls 
within the Ambulance Services benefit category. Your contract with the Plan clearly says that you must pay a 
$250 copayment for Ambulance Services. However, you have only been asked to pay $238.54, which is less 
$250 copayment amount. 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 $238.54 copayment for ambulance 
transportation on February 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce or waive the copayment for a magnetic resonance imaging of 
any joint of the upper extremity provided on February 11, 2022. 
 
You asked the Plan to reduce or waive the copayment for a magnetic resonance imaging of any joint of the 
upper extremity. You say that you are on a fixed income and only receive social security benefits. The Plan 
denied your request. The Plan says you were charged the correct cost sharing 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 $350 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
 You have been asked to pay a $228.44, which is less than the $350 copayment for a magnetic resonance 
imaging of any joint of the upper extremity. A magnetic resonance imaging of any joint of the upper extremity 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce or waive the copayment for a magnetic resonance imaging of any joint of the upper 
extremity provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 vaccine provided on April 20, 2021, to  
May 20, 2021. 
 
You asked the Plan to pay for a COVID-19 vaccine. The Plan denied your request. The Plan says the claim 
needs to be billed to Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare Advantage patients you vaccinated 
in 2021, submit COVID-19 vaccine administration claims to Original Medicare. 
 
We looked at the file and Medicare rules. The rules say that COVID-19 vaccine administration claims must be 
submitted to Original Medicare.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for a COVID-19 vaccine provided on April 20, 2021, 
to May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology and laboratory procedures provided on January 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology and laboratory procedures. You say that the doctors office failed to 
send in a preauthorization form for approval. The Plan denied your request. The Plan says the out-of-network 
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 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 pathology and laboratory procedures provided on 
January 31, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on February 2, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that an approved authorization was 
obtained for the procedure. The Plan denied your request. The Plan says the medications billed while the 
enrollee was in the hospital outpatient setting like an emergency department, observation unit, surgery center, 
or pain clinic are considered self-administered drugs which is not covered by the Plan's Part B plan. 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on February 2, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
25, 2021, to June 21, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the RAP has been submitted untimely. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, May 25, 2021.  
  
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from May 25, 2021, to June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99156 and 99157 
provided on June 9, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
 
 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, we have confirmed that codes 
99156 and 99157 are column II codes to column I code 64493 with a modifier indicator of 0. The column II 
codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99156 and 
99157 provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient evaluation and treatment with a tertiary level 
of care provider.  
You asked the Plan to pre-approve outpatient treatment. You say that you need treatment before your condition 
spreads. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because you do not need to be treated at the tertiary level of care at this time and can be treated by a non-
tertiary specialist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient treatment. Our reviewer says 
that you do not meet the Medicare criteria for treatment with the requested tertiary level of care provider. Our 
physician reviewer found you have squamous cell carcinoma of the head and neck that has required multiple 
procedures and therapy. You require additional radiation treatment. A non-tertiary physician is available to 
provide the needed services, but you have not yet seen this physician. The records provided do not support the 
necessity of tertiary level of care at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient evaluation and treatment with a tertiary level of care provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the $22 copayment you paid for an emergency 
room visit on April 2, 2022. 
 
You asked the Plan to reimburse you for the $22 copayment you paid for an emergency room visit on April 2, 
2022. You say that you were dissatisfied with your care. The Plan denied your request. The Plan says you must 
pay a $90 copayment for each emergency room visit. 
 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room 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 reimburse you for the $22 copayment 
you paid for an emergency room visit on April 2, 2022.   
Your complaint about your emergency room care 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on September 14, 2021. 
 
You asked the Plan to pay for the telehealth visit. You say that the GT modifier was added, and the POS was 
corrected. You say that the reports show the exam was medically necessary and the claim should be paid. The 
Plan denied your request. The Plan says modifier GT is for telehealth services and must be billed with place of 
service 2. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the use of the telehealth 
POS Code 02 certifies that the service meets the telehealth requirements. 
 
  In this case, the CPT Code Manual definition of code 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, telehealth services should be 
billed with POS 02. Based on this information, we decided that Medicare rules for coverage of the telehealth 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the telehealth visit 
provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and transitional care 
management services provided on February 25, 2022, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and transitional care management services. You 
say that authorization wasn't obtained prior to seeing this enrollee since it is the nursing facilities responsibility 
to get authorizations. The Plan denied your request. The Plan says the out-of-network 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 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 a domiciliary or rest home visit and transitional 
care management services provided on February 25, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on March 21, 2022, by an out-
of-network provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services were necessary.  The Plan denied 
your request. The Plan says there is no referral letter or authorization on file from an in-network physician. 
 
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 nursing facility care provided on March 21, 2022, 
by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on July 30, 2021. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a covered 
benefit. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of the supply allowance for therapeutic CGM have 
not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic 
continuous glucose monitor (CGM) provided on July 30, 2021.