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

 
We decided that the Plan does not have to pre-approve a special power wheelchair (group 3 power wheelchair) 
with two (2) or more power seat options (power tilt and power seat elevation options) and accessories (K0861, 
E2361, E1028x2, E1002, E2620, E0955, K0040, K0108x2, E0952, E2311, E2607, E2619). 
 
You asked the Plan to pre-approve a special power wheelchair. You say that the requested wheelchair and 
accessories are medically necessary. The Plan denied your request. The Plan says Medicare guidance says that 
a special power wheelchair is medically necessary for individuals that require both power tilt and power 
recline. Only one power option has been requested, power tilt. The upgraded electronics (electronic connector 
to 2 power options) are not medically necessary. They cannot be covered. The enrollee may meet criteria for a 
simpler power wheelchair. 
 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 patients 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 a special power wheelchair. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is documentation 
that this enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily 
living such as toileting, feeding, grooming and bathing in customary locations within the home. The requested 
power seat elevation feature is statutorily non-covered as it serves no primary medical purpose. As only one 
power seating feature is covered (power tilt) the power wheelchair with a multiple power option feature does 
not meet criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a special power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a special power wheelchair (group 3 power wheelchair) with two (2) or more 
power seat options (power tilt and power seat elevation options) and accessories (K0861, E2361, E1028x2, 
E1002, E2620, E0955, K0040, K0108x2, E0952, E2311, E2607, E2619).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 80307 billed for date of service August 3, 2021. 
 
You asked the Plan to pay for code 80307. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 22, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 80307 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 80307 billed for date of service August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from April 1, 2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you were not advised that a 
copayment would apply after the first 20 days of your stay at the rehabilitation center. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment each day for days 1 through 20 and a $188 copayment each day for days 21 through 100 for SNF 
care.  
 
You have been asked to pay a $1,504 copayment for SNF services. The services at issue fall within the skilled 
nursing facility (SNF) care benefit category. From April 1, 2022, to April 20, 2022, a $0 copayment applied. 
However, the remaining 8 days of your stay were assessed with a $188 copayment.  This means that you have been asked to pay the correct amount based on your contract with the Plan ($188 
copayment  8 days = $1,504). 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 skilled 
nursing facility (SNF) stay provided from April 1, 2022, to April 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99283) 
provided on July 8, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the denial. 
 The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for Emergency care.  
 
 
  You have been asked to pay a $100 copayment for the ER visit. This item/service 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 an emergency room (ER) visit 
(99283) provided on July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on August 9, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 principal care management services provided on 
August 9, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on May 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it was medically necessary to treat the 
enrollee and you would like the claim paid. The Plan denied your request. The Plan says the rendering provider 
is an OON provider; therefore, the request for payment has been denied. 
 
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 home health visit provided on May 19, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection on May 13, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for an injection. The total allowed amount of the injections is $2,067.60, resulting in a coinsurance 
amount of $413.52. 
 
You have been asked to pay a 20% coinsurance for an injection. This item/service falls 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 copayment for an injection 
on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that we depend upon the hospital staff to verify eligibility 
and to obtain the proper authorization from the beneficiary's Plan. We do not see the beneficiary here. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
 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 drug testing provided on June 30, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on May 23, 2022, to 
June 08, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for each Medicare-covered outpatient surgery at an outpatient hospital facility. Covered services 
include but are not limited to services in an emergency department or outpatient clinic, such as observation 
services or outpatient surgery. There were two visits. $350 x 2 = $700. Therefore, results in the total cost 
sharing amount of $700. 
 
 
 You have been asked to pay a $350 copayment for each outpatient surgery. This item/service falls within the 
Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
surgery on May 23, 2022, to June 08, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided on July 18, 2022, and July 21, 
2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you were referred to the clinic and 
you had an authorization for the treatment in your records. The Plan denied your request. The Plan says that 
there was an approved authorization that exists, but the service performed, or the provider, or number of visits 
billed do not match. Therefore, the payment for the dates of service were denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There was no documentation forwarded to show what services were authorized 
on the approved authorization. Also, the documentation submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is an out-of-network provider. This means that 
we cannot determine if the Plan was correct to not pay for the outpatient services. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pay for the outpatient hospital services provided 
on July 18, 2022, and July 21, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ambulance ride and emergency room 
services provided on April 4, 2022. 
 
You asked the Plan to waive the copayments for an ambulance ride and emergency room services. You say that 
you fell while being transported to an appointment, and the transport service didn't help you get in or out of the 
transport and left you lying on the ground for 20 minutes until EMS arrived. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment for ambulance services, and a $120 copayment for emergency care.  
 
You have been asked to pay a $290 copayment for ambulance services, and a $120 copayment for emergency 
care, for a total of $410. This item/service falls within the emergency care and ambulance services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for an ambulance ride and emergency room 
services provided on April 4, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 07, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says if the enrollee needs Medicare-covered medical care and a network provider is 
unable to provide this care, the enrollee may be able to get care from an out-of-network provider. Our plan 
must confirm there is not a network provider available, and the out-of-network provider must contact the plan 
to request an authorization for the enrollee to obtain services. If approved, the out-of-network provider will be 
issued an authorization to provide the service(s). 
 
 
 
 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 testing provided on July 07, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
28, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 
 The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 28, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 12, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a continuous positive airway pressure 
(CPAP) machine provided on May 25, 2022. 
 
You asked the Plan to waive the deductible for a CPAP machine. You say that this is an excessive amount of 
money to be charged, in the past it was $30 or less. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 $450 deductible which applies to durable medical equipment (DME) 
and related supplies. At the time of this service, you had not met your deductible, therefore, you are being 
asked to pay the total $144.88. 
 
The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment 
(DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $450 deductible which applies to durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time a CPAP machine was 
received on May 25, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a 
continuous positive airway pressure (CPAP) machine provided on May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on May 04, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 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 x-rays provided on May 04, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy on July 28, 2022, to 
August 26, 2022. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment per provider, per day for occupational therapy. The total cost share for six occupational therapy 
visits is $180. 
 
You have been asked to pay a $30 copayment per provider, per day for occupational therapy. This item/service 
falls within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for occupational therapy on July 28, 2022, to August 26, 2022.