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

 
We decided that the Plan does not have to pay for rest home visit provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for rest home visit. You say that the providers rely on facility staff to verify 
eligibility and obtain authorization from the patient's insurance company. The Plan denied your request. The 
Plan says the enrollee must receive their care from a network provider (for more information about this, see 
Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network provider (a provider 
who is not part of our plans network) will not be covered. 
 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for rest home visit provided on April 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for any of the equipment requested.
You asked the Plan to provide coverage for the requested equipment. You say that the requested power
wheelchair and accessories are medically necessary for the enrollee The Plan denied your request. The Plan
says the medical records provided do not support the equipment requested. Maximus partially overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. Specific records and medical necessity
documentation was requested from the ordering physician. We asked for specific records and documentation to
show why the enrollee needs both the power tilt and power recline features. Coverage for the requested Group
3 Power wheelchair can only be approved if the medical records support the need for both of these items.
A response and additional records were not submitted for review. Therefore, we decided that the Plan does not
have to provide coverage for a Group 3 standard power wheelchair (K0861) and components including a power
seating system (E1012), manual swing away wheelchair accessories (E1028), an expandable controller (E2377)
with harness (E2313) and electronic connection (E2311), a thigh or knee support (E0953), a cushioned headrest
(E0955), a side or hip support (E0956), a positioning seat cushion (E2606), and a power seat elevation system
(E2300).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 12, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this should be covered. The Plan denied your request. 
The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. 
The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on May 18, 2022, to 
May 25, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you dont usually pay for IVs in the 
hospital. 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 Intravenous, subcutaneous, and biological Part B drugs. 
 
You have been asked to pay 20% coinsurance for injections. This item/service falls within the Intravenous, 
subcutaneous, and biological Part B 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 May 18, 2022, to May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on 
March 28, 2022. 
 
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that this was an office visit 
in a doctors office. 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 
$138.91 copayment for outpatient hospital or hospital outpatient surgical facility visits. 
 
You have been asked to pay a $138.91 copayment for the outpatient clinic visit. This item/service falls within 
the outpatient hospital or hospital outpatient surgical facility 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. Per the EOC, there is a $475 copayment for 
hospital outpatient visits. Since the allowed amount of $138.91 is less, you are only responsible for the lesser 
amount. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient clinic 
visit provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine exam and the eye refraction provided by an out-
of-network provider on July 7, 2022.  
You asked the Plan to pay for the routine exam and the eye refraction. You say that you have seen this provider 
since 1989. You say the Plan's providers are not familiar with your vision issues. The Plan denied your request. 
The Plan says the provider was out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided with an in-network optical provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the routine exam and the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the routine exam and the eye refraction 
provided by an out-of-network provider on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient clinic visit provided on 
January 24, 2022. 
 
You asked the Plan to waive the deductible for the outpatient clinic visit. You say that you only received a 
vaccine in your doctors office. 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 $250 
deductible for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $250 deductible for the outpatient clinic visit. This item/service falls 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 deductible for the outpatient clinic visit provided on January 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (A4550, S0020) provided to the 
enrollee on March 2, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these items were not reported correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. We also find 
that procedure code S0020 has a status indicator of I on the Physician Fee Schedule. This means that procedure 
code A4550 is not separately payable and S0020 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of procedure code A4550 and S0020 have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services (A4550, S0020) provided to 
the enrollee on March 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography procedure provided on 
May 11, 2022. 
 
You asked the Plan to waive the copayment for echocardiography procedure. You say that you had an 
echocardiogram (non radiological) therefore, you should not have to pay for the test. 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 $110 
copayment for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $110 copayment for echocardiography procedure. This item/service falls within 
the radiological diagnostic services, not including x-rays 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 echocardiography procedure provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility visit. You say that you have treated patients at this facility 
before and haven't had an issue. The Plan denied your request. The Plan says there was no preauthorization by 
a primary care provider (this is different than a referral) for an OON provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing facility visit provided on March 17, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an ultrasound, diagnostic mammography, 
and tomosynthesis (G0279, 76642, 77066) provided on June 27, 2022. 
 
You asked the Plan to waive the cost-sharing for the ultrasound, diagnostic mammography, and tomosynthesis. 
You say that the services should be covered as you disagree with the denial. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible and a $20 copayment which applies to Outpatient 
diagnostic tests and therapeutic services and supplies.  
 
 
  The item or service you asked the Plan to waive the cost-sharing for falls within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible and a $20 copayment which applies to Outpatient 
diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not 
been met at the time the ultrasound, diagnostic mammography, and tomosynthesis was received on June 27, 
2022. Therefore, we decided that the Plan does not have to waive the cost-sharing for an ultrasound, diagnostic 
mammography, and tomosynthesis (G0279, 76642, 77066) provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 17, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you only saw this provider for 5-
10 minutes and dont feel you should have to pay this large copay. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist visit. This item/service falls 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 a specialist visit provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on June 03, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you had injections before, and you 
never had to pay anything in the past. 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 injections. This item/service falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the coinsurance for injections provided 
on June 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 power wheelchair with power tilt
and recline.
You asked the Plan to provide coverage for a Group 3 power wheelchair with power tilt and recline. You say
that the requested power wheelchair and accessories are medically necessary. The Plan denied your request.
The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 power
wheelchair with power tilt and recline. Maximus original overturned the denial.
The Plan requested a reopen and stated there is no specific clinical documentation provided that would support
you are at a "high risk" for the development of a pressure ulcer in the area directly affected by a power tilt
option and that the member cannot also be reasonably expected to perform a functional weight shift, or has the
need to use intermittent bladder catheterization, or has increased tone or spasticity in the bilateral lower limbs.
The medical records show you have a medical history that includes multiple strokes, diabetes with neuropathy,
obesity, and pulmonary disease. The face-to-face appointment on February 7, 2022, documents your gait as
normal, and also that you are unable to ambulate. The upper and lower extremity strength reported was 3 out of
5. The Plan is correct in this case. There is insufficient clinical documentation to support a high risk for
development of a pressure ulcer or that you are unable to perform a functional weight shift, or utilize
intermittent catheterization for bladder management, or that a power seating system is needed to manage
increased tone or spasticity. Therefore, Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Group 3 power wheelchair with power tilt and recline have not been met.
Therefore, we decided that the Plan does not have to provide coverage for a Group 3 power wheelchair with
power tilt and recline.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33286 billed for date of service January 19, 
2022. 
 
You asked the Plan to pay for procedure code 33286. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 33286 is bundled into payment for code 33285. 
 
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 33286 
is a column II code to column I code 33285. 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 33286 billed for date of service January 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided on 
September 28, 2021, to December 21, 2021. 
 
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that the charges are 
vague with no explanation. 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 therapeutic radiology services. 
 
You have been asked to pay 20% coinsurance for the radiation therapy services. This item/service falls within 
the therapeutic radiology 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 
the radiation therapy services provided on September 28, 2021, to December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
June 14, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that you were 
admitted the next day. 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 emergency care. 
 
You have been asked to pay a $120 copayment for the emergency room (ER) visit. This item/service falls 
within the emergency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The records show that you were kept in the hospital under observation care only. The Plan 
has also removed the charges for the drugs received during the ER visit. Therefore, we decided that the Plan 
does not have to waive the copayment for the emergency room (ER) visit provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction (92015) provided on June 22, 2022. 
 
You asked the Plan to pay for the refraction. You say that you cannot pay for this service. The Plan denied your 
request. The Plan says this service is not covered by Medicare. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The contract clearly states that eye refractions are not covered. Based 
on this information, we decided that the Plan's rules for coverage of the refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for the refraction (92015) provided on June 22, 2022.