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

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral appliance provided on February 10, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for oral appliance. You say that you are requesting lenience in regards to your 
misunderstanding of how the process works. The Plan denied your request. The Plan says the denial of 
payment for this item is correct, because prior authorization is required for this item but was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that out-of-network items and services may be covered by the Plan under the Plans Point of Service 
(POS) benefits, but that prior authorization is required for durable medical equipment (DME) items that cost 
more than $1,000. 
 
The requested provider in this case is not a network provider with the Plan. The purchase price of this item is 
more than $1,000. Prior authorization was not obtained for this item. We found no exception that would require 
the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for an oral appliance 
provided on February 10, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely 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 not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for back surgery. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the visit was medically appropriate, and you would 
like the claim reprocessed. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 provided on March 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on February 24, 
2022 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were quoted a different amount 
and feel you should not need to pay the current amount. The Plan denied your request. The Plan says the 
coinsurance applied was 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 a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $2512 resulting in a 
coinsurance amount of $502.40 ($2512 x 20% = $502.40). 
 
You have been asked to pay a $502.40 coinsurance for an injection. An injection falls within the Medicare Part 
B Prescription Drugs - Chemotherapy 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 
an injection provided on February 24, 2022. Your complaint about not being given the correct coinsurance amount is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $92.72 coinsurance for medical supplies provided 
November 10, 2021, to February 8, 2022. 
 
You asked the Plan to waive the $92.72 coinsurance for medical supplies. You say that should not be 
responsible for this because you were not told there would be additional charges for medical supplies. The Plan 
denied your request. The Plan says the coinsurance has been applied 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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay a $92.72 coinsurance for medical supplies. Medical supplies fall within the 
Durable Medical Equipment (DME) and Related 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 $92.72 coinsurance for medical supplies provided November 10, 2021, to February 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture visit you had on March 15, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says that this service is not 
covered when provided by an acupuncturist. 
 
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 contract states that up to 20 acupuncture visits are covered for any 
condition with a licensed acupuncturist. The Plan has not provided documentation showing that this benefit has 
been exhausted. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the acupuncture visit you had on March 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI. You say that you have seen this provider before for an x-ray. The 
Plan denied your request. The Plan says the requested provider is an OON provider and there are 3 in-network 
providers within the enrollee's service area that provide the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a magnetic resonance imaging (MRI) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid or assistive listening 
device/supplies/accessories (V5267) provided on November 11, 2021. 
 
You asked the Plan to pay for the hearing aid or assistive listening device/supplies/accessories. You say that 
your hearing aids were insured to keep them in good working order, and you have extended the insurance 
coverage for one more year. The Plan denied your request. The Plan says hearing aids must be purchased 
through the Plan's approved hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's approved hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid or assistive listening device/supplies/accessories have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aid or assistive listening device/supplies/accessories 
(V5267) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on July 22, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that there was 
no need for hospital treatment. The Plan denied your request. The Plan says Medicare only covers ambulance 
transport. The Plan also says that Medicare does not cover paramedic assessment when there is no transport to 
the hospital regardless of the medical necessity or the reason that you were not transported. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on December 20, 
2021, and January 3, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you received on February 22, 2022, 
which specifically states that if you purchase eligible at-home tests out of pocket prior to February 15, 2022, or 
from a retailer not in the pharmacy network, the Plan will reimburse you. The Plan denied your request. The 
Plan says the at-home COVID-19 tests were not a covered benefit at the time of purchase. 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for over the counter (OTC) 
items and the at-home COVID-19 tests is an OTC item. However, during 2022 the Plan offers a supplemental 
benefit for over-the-counter home COVID-19 tests purchased after February 1, 2022. These tests were 
purchased on December 20, 2021, and January 3, 2022, which is before this benefit went into effect. Therefore, 
we decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on December 20, 
2021, and January 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the removal of skin lesions on the feet 
performed November 3, 2021, to December 29, 2021. 
 
You asked the Plan to waive the copayments for removal of skin lesions on the feet. You say that you should 
not be responsible for the copayments because the coding for these services is incorrect. The Plan denied your 
request. The Plan says the cost share has been applied 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 $30 
copayment for Podiatry Services.  
 
You have been asked to pay a $30 copayment per in-network service for the removal of skin lesions on the feet. 
Removal of skin lesions on the feet falls within the Podiatry 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 copayments for the removal of skin lesions on the feet performed November 3, 
2021, to December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
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 medically necessary care is available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of spine (72114), x-ray of pelvis (72170), and 
office visit (99203) provided on December 30, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that the claim should be reviewed. 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 x-ray of spine (72114), x-ray of pelvis (72170), and office 
visit (99203) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on February 11, 2022 from an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like to be reimbursed $4,800 for the 
hearing aids. The Plan denied your request. The Plan says you did not contact the Plan's approved hearing aid 
vendor prior to purchasing the hearing aids to confirm benefits or register for the hearing aids. The Plan also 
says that you have no OON coverage for hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids purchased on February 11, 2022 from an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services provided on February 18, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the referring provider ordered the test, and 
you would like the claim reprocessed. The Plan denied your request. The Plan says that the rendering provider 
is an OON provider and the service rendered was not urgent or emergent. 
 
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 claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the radiology services provided on 
February 18, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $150 copayment for ambulance transportation on April 19, 
2022. 
 
You asked the Plan to waive the $150 copayment for ambulance transportation. You say that you should not be 
responsible for this copayment because your care was not matched. The Plan denied your request. The Plan 
says the copayment has been applied 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 $150 
copayment for Ambulance Services.  
 
You have been asked to pay a $150 copayment for ambulance transportation. 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 $150 copayment 
for ambulance transportation on April 19, 2022.  
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a placement of osteopromotive material for a spinal surgery 
(20930) provided on August 26, 2021. 
 
You asked the Plan to pay for a placement of osteopromotive material. You say that you have provided medical 
records to support the services billed. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 20930 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 20930 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of a placement of osteopromotive material have not been met. Therefore, we decided that the Plan does not 
have to pay for a placement of osteopromotive material for a spinal surgery (20930) provided on August 26, 
2021.