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

 
We decided that the Plan does not have to pay for the office visit provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the rendering physician is a hospitalist and depends 
on the hospital staff to obtain proper authorization. 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit 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 COVID-19 vaccination provided on November 5, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccination. You say that it is not acceptable for the Plan to deny 
this claim. The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare Advantage patients vaccinated in 
2021, providers should submit COVID-19 vaccine administration claims to Original Medicare through the 
Medicare Administrative Contractor.  Providers should use the patient's Medicare Beneficiary Identifier (not 
their Medicare Advantage Plan Member ID) to bill Original Medicare. The COVID-19 vaccination provided to 
a this Medicare Advantage enrollee occurred in 2021, so this claim should be paid by Original Medicare (not 
the Plan.)  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 vaccination have not been met. Therefore, we decided that the Plan does not have 
to pay for the COVID-19 vaccination provided on November 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the spine provided on March 31, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you feel the X-rays were not necessary 
and you should be reimbursed for the cost. 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 an $80 
copayment for X-ray services.  
 
You have been asked to pay an $80 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for X-rays of the spine provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Light Emitting Diode (LED) expandable remote with 
lights and LED lights with indicators. 
 
You asked the Plan to pre-approve the LED expandable remote with lights and the LED lights with indicators. 
You say that the documentation provided supports the need for the requested items. The Plan denied your 
request. The Plan says the items which remain in dispute do not serve a primary medical purpose. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Light Emitting Diode (LED) expandable remote with lights 
and LED lights with indicators.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for r extracorporeal photopheresis (36522) provided to the enrollee on November 17, 2021.
You asked the Plan to pay for this treatment. You say that this treatment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial stating while the Medicare regulations were not met, this continued treatment would be beneficial for the enrollee. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare regulations.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of treatment. Whether or not the treatment was or is beneficial is not of issue, the records clearly show the enrollee does not meet the required coverage criteria and did not at the time of service.
Therefore, we decided that the Plan does not have to pay for r extracorporeal photopheresis (36522) provided to the enrollee on November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on March 04, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you did not have surgery 
services on this date of service, and her copayment should be lowered to either $0 or $30 dollars. The Plan 
denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for outpatient hospital surgery.  If you are having surgery in a hospital facility, you should check 
with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to 
admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient 
surgery. Even if you stay in the hospital overnight, you might still be considered an "outpatient." 
 
 
 
  
You have been asked to pay a $295 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery on March 04, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the $702.32 coinsurance for an injection of Zoledronic acid on 
February 25, 2022. 
 
You asked the Plan waive the $702.32 coinsurance for an injection of Zoledronic acid. You say that you have 
had this same type of service before, and it was covered in full. The Plan denied your request. The Plan says 
the coinsurance was 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 the Medicare Part B drugs.  
 
You have been asked to pay a 20% coinsurance for an injection of Zoledronic acid. An injection of Zoledronic 
acid falls within the Part B Drugs 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 waive the $702.32 
coinsurance for an injection of Zoledronic acid on February 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on March 30, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you feel you are being charged the 
wrong copayment. The Plan denied your request. The Plan says the copayment 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 $110 
copayment for outpatient diagnostic tests.  
 
 
 
 
 
 
 
 
 You have been asked to pay the allowed amount of $101.30 which is less than the $110 copayment for an x-
ray. An x-ray falls within the Outpatient Diagnostic Tests at a Outpatient 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 copayment for an x-ray provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for all of the dental services provided.
You say that these dental services should be paid in full by the Plan. The Plan denied your request. The Plan says the benefit maximum of $1250 was exhausted during the receipt of these dental services. Maximus overturned the Plans denial because an Evidence of Coverage or Plan contract was not submitted for review. The Plan requested a reopen and submitted the required contract information.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, your services exceeded the $1250 maximum benefit between the dates of service in question. Any amount over the $1250 maximuM would be your financial responsibility. Therefore, we decided that the Plan does not have to pay for dental services provided from February 16, 2021, to March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 29, 
2020. 
 
You asked the Plan to pay for procedure code 99223. You say that You did not provide a specific argument 
with your appeal request. The Plan denied your request. The Plan says despite multiple requests, no medical 
records have been provided, so medical necessity cannot be determined. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 99223 billed for date 
of service August 29, 2020. have been met. Specifically, you have not provided any medical records for this 
service, so we cannot determine if the services were medically appropriate. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service August 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an octreotide injection provided on March 
15, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were informed that you would 
only have a $25 copayment for the visit. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
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 5% 
coinsurance for each Part B drug.  
 
You have been asked to pay $226.54, which is 5% of the allowed amount for the injection ($4,530.72 allowed 
amount x 5% coinsurance = $226.54). The injection falls within the Medicare Part B Prescription Drugs 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 octreotide injection provided on March 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion orthotic device. 
 
You asked the Plan to pre-approve orthotic device. You say that this is the only available treatment that can 
deliver more intensive practice that meets the enrollee's needs. The Plan denied your request. The Plan says the 
denial of authorization for this device is correct, because this is considered to be investigational. 
 
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 orthotic device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient peer-reviewed literature to assess safety, efficacy, long-term outcomes, or 
patient management associated with the use of this device for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of orthotic device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion orthotic device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service February 12, 2022. 
 
You asked the Plan to pay for code 99223. You say that this is a payable code in an inpatient setting. 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 providers must bill the correct Place of Service 
(POS) code based on where the service occurred.  Providers should bill POS 21 for services rendered in a 
inpatient hospital setting.  Providers should bill POS 22 for services rendered in an outpatient hospital setting.  
Records show that the services in dispute occurred while the patient was in an observation stay at the hospital.  
Observation is an outpatient status, so the correct POS would be an outpatient hospital setting.  However, you 
billed with an inpatient POS code. Therefore, we decided that the Plan does not have to pay for code 99223 
billed for date of service February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment for telehealth services on March 2, 2022. 
 
You asked the Plan to waive the $35 copayment for telehealth services. You say that you should not be 
responsible for the copayment for a two-minute phone call. 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 $35 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $35 copayment for telehealth services. Telehealth services fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 $35 copayment for telehealth services on March 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for knee surgery.
You asked the Plan to provide coverage for inpatient admission for knee surgery. You say that inpatient care for this surgery was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met at the time of the appeal. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an inpatient stay following right total knee arthroplasty. The Maximus Physician Reviewer determined you have a medical history that could place her at increased risk for peri-surgical complications requiring an inpatient stay. The Plan requested a reopen and argues that if an enrollee is stable the same day or after one midnight, she could receive further assistance at a lower level of care if they are unable to be home alone, but they would not meet criteria for an acute inpatient admission. The medical records show you have a diagnosis of primary osteoarthritis of the right knee.
The medical history was notable for T-cell lymphoma and hypertension. Attempts at conservative management had been exhausted. It should also be noted that correspondence dated June 7, 2022, states "Please cancel appeal. Surgery was performed May 4, 2022. Did not stay extra day." The Plan is correct in this case. The documentation does not support that at the time of inpatient admission it was reasonably expected that the enrollee's necessary hospital care would span two midnights. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission for knee surgery have not been met. Therefore, we decided that the Plan does not have to provide coverage for inpatient admission for knee surgery.
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 for the enrollee. 
 
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 the enrollee needs 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery 
bypass grafting, gangrene of the foot and below the knee amputation. The enrollees medical problems are 
stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure improves the quality of 
life of patients suffering from vertebrogenic low back pain. The Plan denied your request. The Plan says this 
procedure is considered experimental and investigational and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
 
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 
vertebral bodies, lumbar or sacral (64628).