Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on July 14, 2022, from 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were told that you would be reimbursed up to 
$500 for new hearing aids every three years. You also say that it has been more than three years since you last 
purchased hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids or 
related services are received from an OON provider. The Plan also says that the hearing benefit is not covered 
if the services are not registered with the Plan's hearing department in advance. 
 
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 from 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 aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased on July 14, 2022, from an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services (99283, 73722, 97110, A999, 
J3490, 87635), provided out of the Country. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services received were not emergent and did not 
require immediate care. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Specifically, the services received were not 
emergent and did not require immediate care. Therefore, we decided that the Plan does not have to pay for the 
emergency room services (99283, 73722, 97110, A999, J3490, 87635), provided out of the Country.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761), provided on July 9, 2022. 
 
You asked the Plan to pay for the elbow orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there is not a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the elbow orthosis (L3761), provided on July 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasounds provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for ultrasounds. You say that you feel you are being overcharged 
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 $50 
copayment for outpatient diagnostic tests/Medicare-covered ultrasound.  
 
You have been asked to pay a $50 copayment for ultrasounds. The total amount you are being asked to pay is 
$200 ($50 x 4 = $200). 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 ultrasounds provided on 
February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 4, 2020. 
 
You asked the Plan to pay for the lab services. You say that this service is payable by Medicare. The Plan 
denied your request. The Plan says this claim must be submitted to the patient's primary insurer first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer and has directed you to bill that primary insurer. As the secondary insurer, the Plan cannot be 
held responsible for the lab services until the primary insurer has denied the claim for these services. Therefore, 
we decided that the Plan does not have to pay for lab services provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that this is medically necessary. 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 out-of-network (OON) provider or facility, and this is 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 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 
chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code G0482. You say that the enrollee has claims that were previously 
paid with the same procedure codes. The Plan denied your request. The Plan says the billed code cannot be 
verified. 
 
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, the CPT Code Manual definition of code G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested. There is a more appropriate code available to support the services provided.  Based on this information, we decided that Medicare rules for coverage of procedure code G0482 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code G0482 billed for date of 
service April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you strongly recommend that the 
enrollee get a glucose meter due to being at risk of hyperglycemia and sulfonylurea and is advanced in age. 
Moreover, this is a safety matter that is needed in diabetes treatment and the enrollee is currently on 4 
medications for diabetes. The Plan denied your request. The Plan says the enrollee does not meet overage 
criteria for the requested CGM and supplies. 
 
 
 
 
 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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous electrical nerve stimulation (TENS) 
device (E0730), provided on June 7, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item was medically necessary. The Plan 
denied your request. The Plan says a valid proof of delivery was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Neither the packing or delivery slip match the date of 
service. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the Transcutaneous electrical nerve 
stimulation (TENS) device (E0730), provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance, half leg (E0673) provided April 15, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are not 
contracted with the facility and are not notified that your product has been issued to the patients. The Plan 
denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep 
vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance, 
half leg (E0673) provided April 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the records provided support the need 
for spinal fusion surgery. The Plan denied your request. The Plan says the requested surgery is not medically 
necessary. 
 
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 spinal fusion surgery. Our reviewer 
says that spinal fusion surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented sacroiliac (SI) joint instability, fracture, or lesion. The enrollee has 
degenerative back pain. There are no previously documented SI joint injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 34713 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 34713. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 34713 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 34713 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 34713 billed for date of service March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed services cannot be verified. 
 
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, the CPT Code Manual definition of code 93229 is external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional. 
 We find that CPT code 93229 is not supported in the medical record. The records include cardiac monitoring 
for day 3 of services. The records do not include the complete analysis and transmission of daily data reports. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 93229 billed for date of 
service April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 08, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the eye doctor requested this visit 
due to eye issues. 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 $25 
copayment for vision care. 
 
You have been asked to pay a $25 copayment for an office visit. This item/service falls within the vision 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 office visit provided on 
September 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81408, 81404, 81406, 81407, 81405, 81439, 
81286, 81403) provided August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed were unbundled and not eligible for separate payment. 
 
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 81408, 81404, 81406, 81407, 81405, 81439, 81286, & 81403 is not supported in the 
medical record. Specifically, the codes billed are included in code 81479. Separate lab reports were not 
provided for each code billed. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(81408, 81404, 81406, 81407, 81405, 81439, 81286, 81403) provided August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you feel you should not pay 
the copayment because they almost killed you. 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 
copayment for in-network outpatient surgery.  
 
You have been asked to pay a $250 copayment for outpatient surgery. This item/service falls within the in-
network outpatient surgery 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 July 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit, and an inpatient 
hospital stay provided from June 2, 2022, to June 17, 2022. 
 You asked the Plan to waive the copayments for an emergency room visit, and an inpatient hospital stay. You 
say that you would like the copayments waived. 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 $90 
copayment per visit for emergency care and the copayment is not waived if admitted to hospital. Your contract 
with the Plan also clearly says that you must pay a $350 copayment per day for days 1-5 per admission with a 
$1,750 maximum copayment per admission. From June 2, 2022, to June 17, 2022, there was a 15 day stay at 
the inpatient hospital. Since it was more than 5 day the maximum copayment charged can only be $1,750. The 
total copayment for both the emergency room visit and inpatient hospital stay was $1,840 ($90 copayment + 
$1,750 copayment). 
 
You have been asked to pay a $90 copayment for the emergency room visit and a $1,750 copayment for the 
inpatient hospital stay. The emergency room visit falls within the emergency care benefit category. The 
inpatient hospital stay falls within the inpatient hospital 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 copayments for an emergency room visit, and an inpatient hospital stay provided from June 2, 
2022, to June 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Dupixent identified with code 96401. 
 
You asked the Plan to pay for Dupixent. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the services rendered are not a covered benefit.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. In addition, we looked at the file and Medicare rules. Dupixent is a self-administered drug. 
This drug was administered in the provider's office via subcutaneous injection. The documentation does not 
support an inability for the enrollee to self-administer this drug. Based on this information, we decided that 
Medicare rules for coverage of Dupixent have not been met. Therefore, we decided that the Plan does not have 
to pay for Dupixent identified with code 96401.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
August 05, 2022, to August 07, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are appealing the 
applied cost share. 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 $150 
copayment for inpatient hospital care. 
 
You have been asked to pay a $150 copayment for inpatient hospital services. This item/service falls within the 
inpatient hospital 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 inpatient 
hospital services provided on August 05, 2022, to August 07, 2022.