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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen 
concentrator for when you leave your house and run errands. The Plan denied your request. The Plan says there 
is no documentation the standard item is not meeting your needs. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
You are specifically requesting the item at issue in this appeal is for use outside of the home. Although this 
item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-covered ambulance mileage (A0888) provided on February 14, 
2022. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you requested the enrollee be 
transported to another hospital because they had previously been there in November and December. The Plan 
denied your request. The Plan says that this is not a covered benefit. 
 
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 Plan did not provide an ambulance trip report or medical records of any 
kind, and did not advise what the closest appropriate facility would have been that the enrollee could have been 
transported to. Without records showing what the enrollee's care needs were, we cannot determine whether this 
was the closest appropriate facility to verify that the non-covered ambulance mileage (A0888) charges are 
correct. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we 
decided that the Plan has to pay for the non-covered ambulance mileage (A0888) provided on February 14, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on November 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on November 17, 2021, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on February 02, 
2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you did not have the procedure 
done. 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 10% 
coinsurance for Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
 
You have been asked to pay 10% coinsurance for the injection. This item/service falls 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. The records show 
a spinal nerve block procedure was performed on February 2, 2022. The allowed amount for this procedure is $1,174.84, and the 20% coinsurance is $117.48. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the injection provided on February 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you do not drive and need 
transportation to get to your medical appointments. The Plan denied your request. The Plan says as of August 
18, 2022, you have used or scheduled 99 one-way trips, and had one trip remaining for 2022. The Plan also 
says your request for trips beyond the 100 trips allowed by the Plan is not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 100 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have, or will have, exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37221 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 37221. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 37221 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 37221 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 37221 billed for date of service March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 9, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 the subsequent nursing facility care provided on 
March 9, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty transfer bench. 
 
You asked the Plan to pre-approve a heavy-duty transfer bench. You say that this equipment is necessary for 
your condition. The Plan denied your request. The Plan says this item is not a covered item under Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty transfer bench.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93971) provided on May 1, 2022. 
 
You asked the Plan to pay 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 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 service at issue was reimbursed by 
the Plan on June 1, 2022. Comparison of the two claims shows that these are exact duplicates. There is no 
evidence presented to support that the billed service was provided twice on the same date. Based on this 
information, we decided that the Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for the extremity study (93971) provided on May 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on March 1, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). 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 supported 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis 
(L0650) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical outpatient hospital visit provided 
on April 28, 2022. 
 
You asked the Plan to waive the copayment for a surgical outpatient hospital visit. You say that the visits were 
medically necessary and appear to be a simple task. You say that you did not expect to pay and believes the 
Plan should cover the payment. The Plan denied your request. The Plan says the copayment 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 a $395 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  You have been asked to pay a $395 copayment for a surgical outpatient hospital visit. A surgical outpatient 
hospital visit falls 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 a surgical outpatient hospital visit provided on April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve Euflexxa injections. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Euflexxa injections. Our reviewer says 
that the documentation does not support that the requested drug is medically reasonable or necessary. Our 
physician reviewer found based on the medical records provided and the Medicare-approved major drug 
compendia there is no documentation that the Euflexxa at issue in this case meets all Medicare criteria for safe 
and effective. As stated in the Medicare-approved drug compendia "Sodium hyaluronate (Euflexxa) intra-
articular injections are indicated to treat osteoarthritis pain of the knee when conservative nonpharmacologic 
therapy and nonsteroidal anti-inflammatory drug or simple analgesics, such as acetaminophen, have failed." 
The provided records do not document trial and failure of nonpharmacologic therapy for this enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Euflexxa injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for back surgery provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for back surgery. You say that this procedure was to correct the 
first procedure I had which had to be stopped. 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 $225 
copayment for outpatient surgery. 
 
You have been asked to pay a $225 copayment for back surgery. This item/service falls within the outpatient 
surgery 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 back surgery provided on 
January 18, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on April 14, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share was applied 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay $90 for an emergency room visit. An emergency room visit falls within 
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 on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are appealing the denial for a chiropractor 
office visit. The Plan denied your request. The Plan says there are equally qualified providers in-network for 
this service. You have been approved to see a physician that is in-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 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 
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision exam provided on February 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the vision exam. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
vision exam. We found no exception that would require the Plan to pay for the vision exam. The records 
provided for review do not show that the vision exam was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the vision exam provided on February 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on March 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the claim was denied for duplicate 
submission and the correction was made to include authorization. The Plan denied your request. The Plan says 
no prior authorization was 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 did not pre-approve the 
home health visit. We found no exception that would require the Plan to pay for the home health visit. The 
records provided for review do not show that the home health visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the home health visit provided on March 21, 2022, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for x-rays provided on April 5, 2022, and 
May 10, 2022. 
 
You asked the Plan to waive the copayments for x-rays. You say that this should be covered. The Plan denied 
your request. The Plan says the copayments applied are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for each basic imaging service (e.g., general x-rays or ultrasound).  
 
You have been asked to pay $40 ($20 x 2) copayment for x-rays. X-rays fall 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 waive the copayments 
for x-rays provided on April 5, 2022, and May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for a CGM have not been satisfied. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).