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

We decided that the Plan does not have to pay for the GTC (genomic testing cooperative) Hematology Profile provided to the enrollee on March 3, 2022.
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was approved by the MolDX program and was medically necessary. The Plan denied your request. The Plan says that the specimen was collected in an outpatient facility.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the GTC (genomic testing cooperative) Hematology Profile provided to the enrollee on March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) provided on July 14, 2022.

You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you should not be responsible to pay this. 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 $125 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $125 copayment for magnetic resonance imaging (MRI). This item/service 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 waive the copayment for magnetic resonance imaging (MRI) provided on July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a CPAP device (E0562 and E0601) for the enrollee.
You asked the Plan to provide coverage for this device. You say that this device is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for a CPAP device. Based on the medical records provided, those criteria were not met at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for a continuous positive airway pressure (CPAP) device (E0562 and E0601) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nivolumab and relatlimab-rmbw (Opdualag) for the enrollee.
You asked the Plan to pre-approve Opdualag. You say that Opdualag is medically necessary. The Plan denied your request. The Plan says Opdualag is second line and not indicated per compendia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. Our Medical director looked at the case file and the reopen request. At issues is coverage for Opdualag. Our Medical Director states that he treatment regimen of Nivolumab and Relatiman-rmbw is listed in NCCN as a second-line or subsequent therapy for patients who experience disease progression with BRAF-targeted therapy. The enrollee in this case is BRAF negative. Our physician reviewer found that the enrollee's condition did not meet criteria for coverage of Opdualag.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdualag have not been met. Therefore, we decided that the Plan does not have to pre-approve nivolumab and relatlimab-rmbw (Opdualag) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visits provided on June 
8, 2022, June 30, 2022, and August 29, 2022. 
 
You asked the Plan to waive the copayment for the specialist visits. You say that you did not see a specialist. 
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 $40 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office. 
 
 
 
 
 You have been asked to pay a $120 copayment for the specialist visits ($40 x 3 visits = $120). These 
items/services fall within the physician/practitioner services, including doctors office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the specialist office visits provided on June 8, 2022, June 
30, 2022, and August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 pre-approve the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphine sulfate provided on April 06, 2022. 
 
You asked the Plan to pay for the morphine sulfate. You say that there are no network providers available to 
provide necessary care. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the morphine sulfate 
provided on April 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network magetic resonance imaging 
(MRI) leg scan provided on September 30, 2022. 
 
You asked the Plan to reduce the copayment for an in-network magetic resonance imaging (MRI) leg scan. 
You say that this should be a $175 copayment and you would like this to be lowered. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for an in-network magetic resonance imaging (MRI) leg scan. 
This item/service 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 the copayment for an in-network magetic resonance imaging 
(MRI) leg scan provided on September 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that treat and 
release is an exclusion in all Medicare products and is to be denied to patient liability not provider write off. 
The Plan denied your request. The Plan says the first decision to deny coverage and/or payment for the service 
was right. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 
 The ambulance company did not provide transport services on June 5, 2022. Specifically, the record shows that 
the enrollee refused transportation. The ambulance benefit is a transportation benefit. When there is no 
transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan 
does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (99210) provided on September 6, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 99210 is not supported in the medical record. Specifically, the claim was billed with 
Place of Service 10. Per Medicare guidance, POS 10 is not valid. Based on this information, we decided that 
Medicare rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan 
does not have to pay for telehealth services (99210) provided on September 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 8, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel that you should 
not be responsible for this copayment. 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 each one-way Medicare-covered ambulance transport. 
 
You have been asked to pay a $225 copayment for the ambulance services. This item/service falls within the 
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 copayment for the ambulance 
services provided on October 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient laser eye surgery provided on 
October 24, 2022. 
 
You asked the Plan to reduce the copayment for an outpatient laser eye surgery. You say that the cost sharing 
for this service should be lower. 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 $120 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility. 
 
You have been asked to pay a $120 copayment for an outpatient laser eye surgery. This item/service falls 
within the Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility 
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 the copayment for an outpatient laser eye surgery 
provided on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D; 25 hydroxy testing (82306) provided on 
August 15, 2022. 
 You asked the Plan to pay for the Vitamin D testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this testing is not a Medicare benefit for the diagnosis listed on the claim 
and is done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Vitamin D testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the Vitamin D; 25 hydroxy testing (82306) provided on August 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 9, 2022, to 
April 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 9, 2022, to April 
6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the denosumab injection provided on 
September 20, 2022. 
 
You asked the Plan to reduce the coinsurance for the denosumab injection. You say that you thought it would 
only be a $47 copayment like the pharmacy charge. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the denosumab 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 reduce the coinsurance for 
the denosumab injection provided on September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 26, 
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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for outpatient surgery. 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. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided on 
October 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90837) provided on April 
13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837) provided on April 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hearing aids, the dispensing fee, and the hearing aid 
examination provided on September 20, 2022. 
 
You asked the Plan to pre-approve the hearing aids, the dispensing fee, and the hearing aid examination. You 
say that you assumed the products and the service had been approved. The Plan denied your request. The Plan 
says the services are not covered when received by an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids, the dispensing fee, and the hearing aid examination have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the hearing aids, the dispensing fee, and the hearing aid 
examination provided on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483, 80307) provided on October 1, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that the insurance information was only recently 
received. The Plan denied your request. The Plan says a corrected claim must be submitted within one year 
from the date of the initial determination or redetermination for any reason. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the drug testing was not filed until October 19, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the drug testing (G0483, 80307) provided on October 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan of the 
chest provided on October 21, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan of the chest. You say that you 
do not agree with the cost sharing applied to this service. 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 $50 
copayment for in-network Medicare-covered computed tomography (CT) scans performed at a non-hospital 
facility. 
 
You have been asked to pay a $50 copayment for computed tomography (CT) scan of the chest. This 
item/service falls within the in-network Medicare-covered computed tomography (CT) scans performed at a 
non-hospital facility 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 computed 
tomography (CT) scan of the chest provided on October 21, 2022.