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

 
We decided that the Plan does not have to pay for the services provided on February 14, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 
services 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 the services provided on February 14, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on February 4, 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 the service was rendered by an out-of-network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on February 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from July 15, 2021, to 
September 9, 2021. 
 
You asked the Plan to pay for the psychotherapy. You say that this providers services are essential to your 
recovery from addiction. The Plan denied your request. The Plan says a licensed professional counselor (LPC), 
which per Medicare and the Plan benefit is not listed for eligible providers. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
July 15, 2021, to September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer provided on January 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the nebulizer. You say that the nebulizer was for COVID-19, and your plan pays 
for COVID-19 treatment. 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 
nebulizer. We found no exception that would require the Plan to pay for the nebulizer. The record shows the 
DME supplier was out-of-network. Therefore, we decided that the Plan does not have to pay for the nebulizer 
provided on January 17, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wound (12013) and 
emergency department (99283) provided on September 29, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the claim should be reprocessed and paid. 
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the simple repair of superficial wound (12013) and 
emergency department (99283) provided on September 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not given 
options for another form of transportation. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
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 
ambulance transportation provided on February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from January 31, 2022, to 
February 2, 2022. 
 
You asked the Plan to pay for the inpatient admission. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says this request for approval of hospital inpatient admission 
is denied as not medically necessary. 
 
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 pay for the inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found there was no indication on admission that the enrollee would likely require inpatient 
services that would likely cross 2 midnights. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from January 31, 2022, to February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to waive or reduce the coinsurance for dental services provided October 6,
2021, to November 3, 2021.
You asked the Plan to pay more of the cost of these services. The Plan denied your request. The Plan says the
contract is clear on what dental services are covered in and out of network and what the cost share expectations
will be. Maximus partially overturned the Plans denial as part of the dental contract had not been submitted for
review. The Plan requested a reopen and provided that portion of the contract required for review.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Based on the services provided and the dental contract with the Plan, the coinsurance charged for these services
was applied correctly and that information was available in the contract literature prior to the service being
rendered. Therefore, we decided that the Plan does not have to pay for dental services provided October 6,
2021, to November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for anesthesia (99100, 00145) provided on 
October 21, 2021. 
 
You asked the Plan to waive the coinsurance for the anesthesia. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied correctly 
based on 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 4% coinsurance for Outpatient surgery, including services provided at hospital facilities and 
ambulatory surgical centers.  
 
 
  The enrollee has been asked to pay a 4% coinsurance for the anesthesia (allowed amount is $210.62 x 4% = 
$8.42). Anesthesia falls within the Outpatient surgery, including services provided at hospital facilities and 
ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
anesthesia (99100, 00145) provided on October 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy services provided on April 
5, 2022. 
 
You asked the Plan to waive the copayment for the psychotherapy services. You say that you saw a nurse 
practitioner instead of a doctor. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 each therapy visit.  
 
You have been asked to pay a $40 copayment for the psychotherapy services. The psychotherapy services fall 
within the Outpatient Mental Health 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 psychotherapy services provided on April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET/CT scan of the skull base to mid-thigh. The Plan denied your request. 
The Plan says since this is a new cancer, Axumin is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET/CT scan of the skull base to mid-
thigh. Our reviewer says that a PET/CT scan of the skull base to mid-thigh is not reasonable and necessary. Our 
physician reviewer found Axumin is a radioactive diagnostic agent indicated for PET imaging in men with 
suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following 
prior treatment. Our reviewer also found that as this is initial staging, the use of Axumin is not indicated and 
the PET/CT scan is not necessary at this time. 
 
 
 
 
 
 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 PET/CT scan of the skull base to mid-thigh have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base 
to mid-thigh (78815).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient minimally invasive bilateral SI joint fusion 
(CPT code(s): 61783 and 27279). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bilateral sacroiliac joint fusion in the 
setting of bilateral sacroiliac joint instability and prior pelvic fixation have not been demonstrated in the peer-
reviewed literature. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found minimally invasive SI joint fusion is experimental. This enrollee has degenerative back pain 
and there is no objective evidence of SI joint instability on radiographs. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve outpatient minimally invasive bilateral SI joint fusion (CPT code(s): 61783 and 27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) provided on April 28, 2022 by an out-of-
network (OON) provider. 
 
  You asked the Plan to pay for the frames. You say that you were told you only needed to fill the reimbursement 
form out and hand in the receipt, but lack of information was the reason the reimbursement was denied. The 
Plan denied your request. The Plan says the services were provided by a non-contracted provider without 
authorization. 
 
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 authorization is requested for OON covered services. 
 
We looked at the file and the Plan's rules. The record does not show any evidence of a pre-authorization for 
these services. Based on this information, we decided that the Plan's rules for coverage of the frames have not 
been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) provided on April 
28, 2022 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99282) 
provided on April 7, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on 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 $90 
copayment for Emergency care.  
 
You have been asked to pay a $90 copayment for the ER visit. the ER visit 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. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
(99282) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on April 1, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained, you were referred by an out-of-network provider. 
 
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 an office visit (99214) provided on April 1, 2022 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from June 18, 2021, to
June 24, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid as billed. The Plan denied
your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for no
medical records submitted of review. The Plan requested a reopen and submitted the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for the secondary
diagnosis code of G92 (Toxic encephalopathy). The medical records show the enrollee is a 71-year-old woman
with a medical history that included COPD, chronic hypoxic respiratory failure, hypertension, type 2 diabetes,
morbid obesity, and tobacco abuse. The enrollee was admitted to the hospital on June 18, 2021, with an acute
exacerbation of COPD. The enrollee was ill-appearing but was not in respiratory distress. Tachypnea,
accessory muscle usage, prolonged expirations, and wheezing were documented. The enrollee was alert and
oriented to person, place, and time. At the time of admission, the enrollee was in no acute distress, and had no
focal neuro deficits. Throughout the stay, the enrollee was described as aggressive and argumentative. The
enrollee was discharged from the hospital on June 24, 2021. The enrollee refused transfer to a skilled nursing
facility after it had been arranged and elected to go home. The Plan is correct in this case, the documentation in
the case file does not support a secondary diagnosis code of G92 (Toxic encephalopathy) in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided to the enrollee from June 18, 2021, to June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on April 4, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were not aware the chiropractor needed an auth. 
The Plan denied your request. The Plan says this service is not covered when it is billed by a chiropractor. 
 
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 an office visit provided by a chiropractor on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and x-ray (99204, 73562) provided on 
December 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and x-ray. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 an office visit and x-ray (99204, 73562) provided 
on December 9, 2021 by an out-of-network (OON) provider.