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

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on February 22, 
2022. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, and 84295 billed for date of 
service November 11, 2021. 
 
You asked the Plan to pay for procedure codes 82435, 84132, and 84295. You say that you have provided 
records to support payment. The Plan denied your request. The Plan says payment for codes 82435, 84132, and 
84295 is bundled into payment for code 80051. 
 
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 
82435, 84132, and 84295 are column II codes to column I code 80051. 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 codes 82435, 84132, and 84295 
billed for date of service November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on January 1, 2021. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as 
valid proof of payment has not been submitted. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of the health club membership purchased have not been met because a television 
subscription for fitness classes is not listed as a covered benefit. Therefore, we decided that the Plan does not 
have to issue reimbursement for the health club membership (S9970) purchased on January 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
13, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you needed these 
services and should have the copayment waived based on this issue. The Plan denied your request. The Plan 
says the copayment applied was 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 a $120 
copayment for emergency care.  
 
You have been asked to pay a $120 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 waive the copayment for an 
emergency room visit provided on April 13, 2022, to April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) testing (87500, 
87652, 87640, 87653) provided December 1, 2021. 
 
You asked the Plan to pay for the urine PCR testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is investigational and non-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 the urine PCR testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture and susceptibility studies. There is lack of support for the clinical utility of large multiplex PCR 
urinary tract infection panel tests. 
 
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 urine PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for urine polymerase chain reaction (PCR) testing (87500, 87652, 87640, 87653) provided 
December 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial of SNF admission. The 
Plan denied your request. The Plan says you do not require daily skilled therapy that can only be provided on 
an inpatient basis in an SNF. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 97110. You say that this is supported in the records. The Plan 
denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526. 
 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 97110 
is a column II code to column I code 92526, which was previously billed and paid. 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 97110 billed 
for date of service March 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for WATS-3D Histocytology (88361) provided December 7, 2021. 
 
You asked the Plan to pay for the WATS-3D Histocytology. You say that this service was medically necessary. 
The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the WATS-3D Histocytology. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the American Society of Gastrointestinal Endoscopy suggests using WATS-3D in patients with 
known or suspected Barrett's esophagus, in addition to Seattle protocol biopsy sampling. 
 
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 WATS-3D Histocytology have been met. Therefore, we decided that the 
Plan has to pay for WATS-3D Histocytology (88361) provided December 7, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services (76514, 92020, G0463, 92133) 
provided from February 10, 2022 to March 10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services should be covered as 
you disagree with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as they were non-emergent and prior 
authorization was not obtained. 
 
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 outpatient hospital services (76514, 92020, 
G0463, 92133) provided from February 10, 2022 to March 10, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for intravenous infusions and lab test on April 
21, 2022, to May 19, 2022. 
 
You asked the Plan to waive the cost sharing for intravenous infusions and lab test. You say that you had these 
injections before and did not pay anything. This is a hurtful thing because you are on a fixed income and could 
not afford this. The Plan denied your request. The Plan says the cost sharing you are being charged is 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 a 20% 
coinsurance of the total cost for other Medicare-covered Part B drugs. These drugs are covered under Part B of 
Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
include drugs that usually arent self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. You must pay a $5 copay for each Medicare-covered lab service. Covered services include but are not limited 
to laboratory tests. The provider billed in the amount of $575 and the allowed amount is $122.76. $122.76 x 
20% = $24.55. There were 5 visits. $24.55 x 5 = $122.75. $122.75 + $5 = $127.75. Therefore, results in the 
total cost sharing amount of $127.75.   
 
You have been asked to pay a 20% coinsurance for intravenous infusions and $5 copayment for lab test. 
Intravenous infusions and lab test falls within the Medicare Part B prescription drugs and Outpatient 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 waive the cost sharing for 
intravenous infusions and lab test on April 21, 2022, to May 19, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation provided on April 25, 2022. 
 
You asked the Plan to pay for the ambulance transportation. You say that you do not understand why this 
would not be covered since the enrollee fell and required stitches due to the injury. The Plan denied your 
request. The Plan says that the documentation does not support medical necessity. 
 
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. The documentation does not show that the Plan made any attempt to receive 
medical records from the ambulance provider in this case. The claim was denied for lack of evidence of 
medical necessity. It is not possible for Maximus to review whether these services were medically necessary 
without medical documentation. We find that the denial of payment for these services is not supported. 
Therefore, we decided that the Plan has to pay for the ambulance transportation provided on April 25, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient procedure provided by an 
out-of-network provider on February 24, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient procedure. You say that you do not agree with the 
cost-share responsibility on this claim and would like the claim to be reprocessed and paid. You say that you 
were told the doctor was under contract with the Plan. The Plan denied your request. The Plan says the 
coinsurance applied is 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 50% 
coinsurance for an out-of-network surgery services provided by an outpatient hospital.  
 
 
  You have been asked to pay a coinsurance of $529.02, which is 50% of the allowed amount for an outpatient 
procedure, ($1,058.05 x 50%). An outpatient procedure 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 coinsurance for an outpatient procedure provided by an out-of-
network provider on February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the wheelchair and accessories provided on 
January 10, 2022. 
 
You asked the Plan to waive the cost share for the wheelchair and accessories. You say that you were advised 
that the wheelchair would be 100% covered. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $203 deductible which applies to DME. Your contract with the Plan 
also says that you must pay 20% coinsurance for DME. 
 
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 your $203 deductible applies to the wheelchair and accessories.  This cost sharing is a contractual obligation that had not been met at the time the wheelchair and accessories 
was received on January 10, 2022. Therefore, $203 has been applied to meet your deductible. 
 
Since the $203 deductible was met, you have also been asked to pay 20% for the wheelchair and accessories. 
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 the 
Plan does not have to waive the cost share for wheelchair and accessories provided on January 10, 2022
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on April 5, 2021. 
 
You asked the Plan to pay for the ambulance transportation. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says this cannot be separately paid by Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that when a beneficiary is an inpatient in a facility 
and requires transport elsewhere for specialized care, while maintaining inpatient status at the original provider, 
no separate Part B payment can be made for the transportation.  We looked at the file and Medicare rules. The beneficiary was an inpatient at the receiving facility and had 
been sent to the origin facility for a specialized procedure. As such, this is considered patient transportation and 
is not separately payable. Payment must be sought from the facility at which the beneficiary was an inpatient at 
the time of transport. Based on this information, we decided that Medicare rules for coverage of the ambulance 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on July 29, 2021, to 
November 18, 2021. 
 
You asked the Plan to waive the coinsurance for injections. You say that you thought this was fully covered. 
The Plan denied your request. The Plan says the coinsurance applied is 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% of 
the cost.  
 
You have been asked to pay $1,685.14 which is 20% of the cost 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 provided on July 29, 2021, to November 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897) treatment. 
 
You asked the Plan to pre-approve Prolia. You say that you were previously taking a monthly medication, but 
you say that you sometimes forgot to take it at the beginning of the month. You say it would be much easier for 
you to get the Prolia treatments twice a year. The Plan denied your request. The Plan says the medical records 
do not support coverage of Prolia. The Plan says the requirements for covering Prolia include a diagnosis of 
osteoporosis and a trial of one intravenous bisphosphonate therapy (such as zoledronic acid). 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Prolia. Our reviewer says that you do 
not meet the criteria for coverage of Prolia. Our physician reviewer found the provided medical records do not 
support the safety or efficacy of Prolia, nor is there documentation that the drug is otherwise medically 
reasonable and necessary. Our reviewer says that the records do not indicate a diagnosis of osteoporosis by T-
score or a history of a fragility fracture. In addition, there is no record of a trial and failure, or adverse reaction 
to treatment with zoledronic acid. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897) treatment.