Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the additional copayment for the eye surgery provided on February 3, 
2022. 
 
You asked the Plan to waive the additional copayment for the eye surgery. You say that you were told that you 
would have only one copayment of $225, but you have been charged two. You do not agree with this. The Plan 
denied your request. The Plan says that the contract states that there is a $225 copayment for surgery provided 
in an ambulatory surgical center and that both the facility and the physician may apply a copayment. 
 
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's originally sent case file included documentation for another enrollee 
and the Evidence of Coverage (EOC) of a different contract ID. Maximus requested the correct file and the 
correct EOC. No corrected EOC was submitted. Without the correct EOC, we cannot review whether the cost 
sharing applied was correct. In addition, though this dispute is regarding the application of two copayments, the 
Plan did not provide copies of both Explanations of Benefits. Even if we had received the corrected EOC, we 
would be unable to determine what copayments were applied to both the facility and physician claim. Based on 
this lack of information, we find that the second copayment applied for this surgery is not supported. Therefore, 
we decided that the Plan has to waive the additional copayment for the eye surgery provided on February 3, 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the services of home health/hospice aide in home health 
or hospice settings, each 15 minutes (G0156). 
 
You asked the Plan to pre-approve the home health services. You say that please reconsider the denial for home 
health speech therapy visits. The Plan denied your request. The Plan says the records does not support the need 
for a home health aide to make visits. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health services. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested home health aide services. Our 
physician reviewer found based on the medical records provided there is no documentation that the services 
meet the definition of home health aide services as per Sections A, B, C, D & E of Section 50.2 and there is no documentation that the home health aide services are reasonable and necessary to the treatment of the patient's 
illness or injury by the skilled professional staff as defined by Medicare rules. The provided records document 
that the enrollee has at least two family members available 24/7 to provide assistance with his care needs.  
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the services of home health/hospice aide in home health or hospice settings, each 
15 minutes (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF level 
rehabilitation to regain their independence. The Plan denied your request. The Plan says the IRF admission is 
not medically necessary and the services the enrollee needs can be provided in another setting like a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77063, 77067) provided on July 6, 2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. 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 13, 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 the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (77063, 77067) provided on 
July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that enrollee is medically complex and needs IRF to 
regain mobility. The Plan denied your request. The Plan says that this is not medically necessary, and you can 
safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found intense rehab thus IRF criteria have been met and is medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 validity testing billed with code 83789 for date of service 
April 7, 2022. 
 
You asked the Plan to pay for code 83789. You say that this testing was necessary. The Plan denied your 
request. The Plan says validity testing 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 the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 for date of service April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary, and a lower level of care might be 
appropriate. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from being in an IRF. The 
Plan denied your request. The Plan says criteria for admission has not been met. The enrollee's ongoing skilled 
therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine-transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that the requested additional trips are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because 
you have exhausted the routine-transportation benefit for the year. 
 
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 24 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 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 trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11102 and 11103 billed for date of service 
May 5, 2022. 
 You asked the Plan to pay for procedure codes 11102 and 11103. You say that the medical records support the 
separate charges. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that codes 11102 and 11103 are column II codes to column I code 17110. The 
codes at issue have 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 11102 and 11103 billed for date of service May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin injection (J1815) provided on April 6, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin injection (J1815) 
provided on April 6, 2022.  
 Benefits for this item may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies (code A0422) 
provided on April 14, 2022. 
 
You asked the Plan to pay for ambulance oxygen and oxygen supplies. The Plan denied your request. The Plan 
says ambulance oxygen and oxygen supplies are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 
We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, 
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for 
ambulance oxygen and oxygen supplies (code A0422) provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided on July 12, 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 service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation (G0283) provided on July 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(A0429, A0425) provided on January 31, 2021. You asked the Plan to pay for ambulance service, basic life support, emergency transport. The Plan denied your 
request. The Plan says the enrollees claims history indicates they were in an inpatient hospital status on this 
date of service. Ambulance services used for the transportation of a hospital inpatient to another facility for 
diagnostic tests or special treatment for example is considered part of the inpatient admission, and not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. In this case, the documentation has determined the enrollee was 
transported to another facility temporarily for care. This is not separately payable from the inpatient services 
according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
ambulance service, basic life support, emergency transport have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) 
provided on January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression sleeve and compression stockings 
identified with code A6549. 
 
You asked the Plan to pre-approve the compression sleeve and stockings. The Plan denied your request. The 
Plan says these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing. The rules also say that 
Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose.  
 
Although the compression stocking may be appropriate, it does not fall into a covered benefit category and 
cannot be paid for by Medicare or the Plan. The compression sleeve 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 
compression sleeve and compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to provide reimbursement for the Medicare-allowable for the appropriate standard 
bifocal/trifocal code. We decided that the Plan does not have to provide reimbursement for the cost beyond the 
standard bifocal/trifocal reimbursement.  
 
You asked the Plan to provide reimbursement for the eyeglasses purchased after cataract surgery on March 23, 
2022. You say that you were told that you would be reimbursed for eyewear purchased after cataract surgery. 
You feel that the $500 you paid should be reimbursed. The Plan says that because you purchased progressive 
lenses, which are not covered, no payment can be made for this purchase. 
 
We decided that the Plan has to provide reimbursement for the Medicare-allowable for the appropriate 
standard bifocal/trifocal code.  
 
The Plan follows Medicare rules. Medicare rules say that while progressive lenses are noncovered, claims are 
to be billed with one of the standard bifocal/trifocal codes listed in the Medicare rules section above, with the 
progressive lens code only representing the additional charge for the non-covered feature. As such, Medicare 
does make payment toward progressive lenses, but not for the upgrade charge to progressive lenses. 
 
Enrollees requesting reimbursement for covered services cannot be expected to know Medicare billing rules. It 
is the Plans responsibility to ensure that payment is made for what is eligible for Medicare coverage, which is 
the allowed amount for the standard non-progressive lenses. Therefore, we decided that the Plan has to provide 
reimbursement for the Medicare-allowable for the appropriate standard bifocal/trifocal code.  
 
We also decided that the Plan does not have to provide reimbursement for the cost beyond the standard 
bifocal/trifocal reimbursement. 
 
The Plan follows Medicare rules. Medicare rules say that the upcharge for progressive lenses is not covered by 
Medicare.  
 
The cost of the eyeglasses beyond the standard lens reimbursement is not covered. Therefore, we decided that 
the Plan does not have to provide reimbursement for the cost beyond the standard bifocal/trifocal 
reimbursement. 
 
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 lab services provided on February 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 7, 2022.