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

 
We decided that the Plan does not have to waive the coinsurance for medical supply provided on December 15, 
2021. 
 
You asked the Plan to waive the coinsurance for medical supply. You say that you cannot pay this bill for a 
small cancer removal. The Plan denied your request. The Plan says the coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each in-network, Medicare-covered medical supply. 
 
 
 
 
 
 
 You have been asked to pay $1,522.12, which is 20% of the allowed amount for medical supply. The allowed 
amount is $7,610.61 (20% x $7,610.61 = $1,522.12). Medical supply 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 coinsurance 
for medical supply provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377), expandable controller harness (E2313) and a power seat elevation feature (E2300) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that it is not medically necessary to control the three approved power 
options through the joystick. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it 
is not primarily medical in nature. 
 
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 an electronic connection, expandable 
controller and expandable controller harness. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. The requested items exceed the patient's need. The 
documentation indicates that the patient has an attendant control and can control the wheelchair with the right 
upper extremity. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311), expandable controller (E2377) and expandable 
controller harness (E2313) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 vaccine provided from April 14, 2021, to  
May 14, 2021. 
 
You asked the Plan to pay for a COVID-19 vaccine. The Plan denied your request. The Plan says the claim 
needs to be billed to Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare Advantage patients you vaccinated 
in 2021, submit COVID-19 vaccine administration claims to Original Medicare. 
 
We looked at the file and Medicare rules. The rules say that COVID-19 vaccine administration claims must be 
submitted to Original Medicare. Therefore, we decided that the Plan does not have to pay for a COVID-19 
vaccine provided from April 14, 2021, to May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate maxillary denture (D5130) provided by a 
participating provider on March 17, 2022. 
 
You asked the Plan to pay for an immediate maxillary denture. You say that you were given prior authorization 
for these services. The Plan denied your request. The Plan says the prior authorization was only valid for 90 
days. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
immediate maxillary denture (D5130) provided by a participating provider on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 19, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 19, 2021 billed with codes 81206 and 81292.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 20, 2021 billed with 
codes 81206, 81301 and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 20, 2021 billed with codes 81206, 81301 and 81311.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
February 24, 2022, through February 28, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $492 
copayment for each Medicare-covered day, for days 1-4 and a $0 copayment for each additional day; for each 
inpatient stay.  
 
You have been asked to pay $1,968 ($492 copayment x 4 days) for the inpatient hospital care provided. 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 inpatient hospital care 
provided from February 24, 2022, through February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 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 December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 30, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 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 laboratory services provided to the enrollee on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the enrollee does not go to your laboratory, so 
they are not using out-of-network benefits because their participating provider sends the specimen. 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 record 
shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for 
laboratory work provided on March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 3, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you dont understand why you 
must pay the full amount. 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 $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
 
 
 
 You have been asked to pay $105.55 which is less than the standard $110 copayment for an ultrasound. 
Ultrasounds 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 copayment for an ultrasound provided on March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 2, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were never told about a 
copayment, and you are on a fixed income. 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 $325 
copayment for surgical services at an outpatient hospital facility.  
 
You have been asked to pay $325 copayment for outpatient surgery. Outpatient surgery 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 March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic panel testing. 
 
You asked the Plan to pre-approve BRCA testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this testing is correct, because the 
enrollee has already received BRCA testing and the results of this testing are not expected to impact treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is limited to once-in-a-lifetime.  
 
We looked at the file and Medicare rules. The enrollee previously received BRCA testing; therefore, additional 
testing is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of 
BRCA testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA 
genetic panel testing.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on December 21, 2021. 
 
You asked the Plan to waive the copayment for ER visit. You say that it was not your fault you had to go to the 
ER so you shouldn't be charged. 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 $90 
copayment per visit for emergency care.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall within the Emergency Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ER visit provided on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that it is medically necessary that 
the enrollee receives the power wheelchair and accessories. The Plan denied your request. The Plan says the 
seat elevator does not serve a primary medical purpose and is statutorily non-covered. 
 
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 wheelchair accessory, power seat elevation system 
(E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically necessary. The enrollee is undergoing a planned 
reverse total shoulder arthroplasty. She is medically stable and has been provided medical clearance to undergo 
this elective procedure. The planned procedure is not listed on the Inpatient Only List. The procedure is 
currently approved as an ambulatory procedure. There is no documentation provided to support the expectation 
that the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's 
condition does not meet criteria for inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 15, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and attached reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service February 15, 
2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that IRF services are medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met for skilled nursing facility
services. Maximus overturned the Plans denial for skilled nursing facility services. The Plan requested a reopen
and stated the services in question were for inpatient rehabilitation facility (IRF) services.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services.
You presented to the acute hospital on June 30, 2022, with multiple injuries suffered in a motor vehicle crash.
You were treated in the hospital for a scalp laceration, sternal fracture, bilateral lower extremity fractures, right
thumb dislocation and other injuries.
You are non-weight bearing with the right upper extremity and both lower extremities. You have been
evaluated by physical and occupational therapy. On July 5, 2022, you experienced hypotension and dizziness.
You are non-ambulatory and require maximum assistance for transfers and most activities of daily living.
Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support
that the complexity of your nursing, medical and rehabilitation needs require an IRF level of care. The
documentation does not support that you require or can tolerate least 3 hours a day /5 day a week, or 15 hours
over 7 consecutive days, of therapy services. The available documentation does not support that you are able to
fully participate in and benefit from and IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on February 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. 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 
genetic testing. We found no exception that would require the Plan to pay for the genetic testing. The records 
provided for review do not show that the genetic testing was urgent or emergent. Therefore, we decided that the Plan does not have to pay for genetic testing provided on February 4, 2022, by 
an out-of-network (OON) provider.