Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of lower extremity arteries provided on 
September 11, 2022. 
 
You asked the Plan to pay for the duplex scan of lower extremity arteries. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the duplex scan of lower 
extremity arteries provided on September 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the endoscope procedure of the bladder 
provided on August 10, 2022. 
 
You asked the Plan to waive the deductible for the endoscope procedure. You say that you believe this service 
should not be applied to the deductible. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to outpatient surgery. Your contract 
with the Plan also says that there is a $300 copayment for Medicare-covered surgery provided to you at an 
outpatient hospital after you have met your deductible. 
 
You have been asked to pay $567.71 towards your deductible. The item or service you asked the Plan to waive 
the deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1,000 deductible which applies to outpatient surgery. This cost 
sharing is a contractual obligation that had not been met at the time the endoscope procedure was received on August 10, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the endoscope 
procedure of the bladder provided on August 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 17, 2022 
 
You asked the Plan to pay for the ambulance response and treatment with no transport provided. You say that 
the emergency personnel did an EKG and said you were ok. You also say you were told it wasn't necessary to 
go to the hospital but were not informed your insurance would not cover the services. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
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 October 17, 2022. 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 provided on October 17, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid check (92593), electroacoustic hearing aid 
evaluation (92595), and the conformity evaluation (V5020) provided on October 18, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the hearing aid evaluations provided are not 
listed as covered benefits under the supplemental policy. Additionally, the conformity evaluation provided was 
not billed on an approved form. 
 
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.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plans contract states that the hearing aid 
evaluations provided in this case are not indicated as covered benefits under the supplemental policy. 
Additionally, the conformity evaluation provided is a covered benefit but was not billed on an approved form 
by the provider. The Plan has contacted the provider regarding the appropriate billing of this service.  Therefore, we decided that the Plan does not have to pay for the hearing aid check (92593), electroacoustic 
hearing aid evaluation (92595), and the conformity evaluation (V5020) provided on October 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 16, 2022, to February 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you want these claims 
checked to make sure they are correct. 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 $385 
copayment per day for days 1-5 of in-network inpatient hospital stays.  You have been asked to pay a $385 copayment per day for days 1-5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,925 ($385 copayment per day x 5 days = $1,925). 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 the inpatient 
hospital stay provided from February 16, 2022, to February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on July 27, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the item is not covered in an ambulatory surgical 
center. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on September 01, 2022. 
 
You asked the Plan to pay for an eye appointment. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an eye appointment 
provided on September 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance used with a therapeutic continuous 
glucose monitor (CGM) device provided on August 14, 2022. 
 
You asked the Plan to pay for the supply allowance used with a therapeutic CGM. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the items rendered are not supported. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation submitted did not sufficiently support the billed supply code. 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 supply allowance used with a therapeutic continuous glucose 
monitor (CGM) device provided on August 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the trifocal lens, the antireflective coating, the 
polarization, and the progressive lens provided on May 9, 2022.  
You asked the Plan to pay for the frames, the trifocal lens, the antireflective coating, the polarization, and the 
progressive lens. You say that you saw another doctor after your cataract surgery in order to get a different 
prescription in order to see better. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 eyewear services once a year. 
 
We looked at the file and the Plan's rules. Specifically, you received routine eyewear on November 18, 2021, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
frames, the trifocal lens, the antireflective coating, the polarization, and the progressive lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames, the trifocal lens, the antireflective 
coating, the polarization, and the progressive lens provided on May 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 21, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 October 21, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 6, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the member was 
under hospice care on this date of service. Therefore, the claim is the responsibility of traditional Medicare. 
 
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 an office visit provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 22, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit provided on 
September 6, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit. You say that you were told that these 
services are covered once a year. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
You have been asked to pay a 10% coinsurance for a specialist visit ($187.35 allowed amount x 10% 
coinsurance = $8.74 rounded to the nearest cent). This item/service falls within the doctors and other health 
care provider services benefit category. You have also been asked to pay $168.61 towards your $800 
deductible for this service. This cost sharing is a contractual obligation that had not been met at the time a 
specialist office visit was received on September 6, 2022. Therefore, we decided that the Plan does not have to 
waive the cost share for a specialist office visit provided on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on November 29, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the eye refraction was medically necessary. The 
Plan denied your request. The Plan says the benefit has been exhausted. 
 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 eye refraction once per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for an eye refraction on April 19, 2022, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
provided on November 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on August 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the cataract surgery. You say that you are a participating provider with the Plan. 
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 
cataract surgery. We found no exception that would require the Plan to pay for the cataract surgery. Therefore, 
we decided that the Plan does not have to pay for the cataract surgery provided on August 31, 2022, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 31, 2022, to November 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had to go to a 
different hospital due to the poor quality of service. 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 $295 
copayment each day for days 1-6 of each in-network Medicare-covered inpatient hospital stay.  
 
You have been asked to pay a $295 copayment each day for days 1-4 of the inpatient hospital stay. You have 
been asked to pay a total of $1,180 ($295 copayment per day x 4 days = $1,180). 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 the inpatient 
hospital stay provided from October 31, 2022, to November 4, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided on March 
03, 2022. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you disagree with the 
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient surgery/surgery performed at an outpatient hospital facility. 
 
You have been asked to pay 20% coinsurance for an outpatient surgery. This item/service falls within the 
outpatient surgery/surgery performed at an outpatient hospital facility 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 outpatient surgery provided on March 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses provided on September 22, 2022. 
 
You asked the Plan to pay for the contact lenses. You say that you disagree with the amount the Plan paid 
towards the contact lenses. The Plan denied your request. The Plan says the benefit has been exhausted. 
 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 offers an allowance of $100 towards contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 towards the contact lenses. Based on 
this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lenses provided on September 22, 
2022.  
 
Your complaint about Medicare fraud 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 pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says this device is not covered when used before or during surgery. Medicare rules state that 
for durable medical equipment to be covered, it must be appropriate and be needed for use inside the home. 
 
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. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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, for 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 October 25, 2021.