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

 
We decided that the Plan does not have to reduce the copayment for specialist office visit provided on July 12, 
2022. 
 
You asked the Plan to reduce the copayment for specialist office visit. You say that you would like this reduced 
to a normal missed appointment charge. 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 Specialist office visits. 
 
You have been asked to pay a $40 copayment for specialist office visit. This item/service falls within the 
Specialist 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 reduce the copayment for specialist 
office visit provided on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatological surgery provided on May 10, 2022. 
 
You asked the Plan to pay for dermatological surgery. You say that you did not know this provider was out of 
the network, and no one at the office told you. 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).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 was not an emergency. Therefore, we 
decided that the Plan does not have to pay for dermatological surgery provided on May 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for x-ray services. 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 $20 
copayment for in-network outpatient diagnostic tests/X-rays.  
 
You have been asked to pay a $20 copayment for x-ray services. This item/service falls within the in-network 
outpatient diagnostic tests/X-rays 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-
ray services provided on May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care physician (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving them a 
"referral." 
 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 lab testing provided on August 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot walk or use the bathroom on your own. 
You are on a catheter and have no bowel movement control. You live alone and if released would not be able 
to care for yourself. You also stated you have severe leg pain. The Plan denied your request. The Plan says the 
request is not medically necessary, the services you require physical therapy and occupational therapy, can safely be received at a different setting. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on January 29, 2020.
You asked the Plan to pay for this claim. You say that this claim was filed timely. The Plan denied your request. The Plan says this claim was not timely filed. Maximus overturned the Plans denial for insufficient claim information. The Plan requested a reopen and provided additional documentation to show the original claim filed was not legible and a timely filed claim was not submitted.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a valid claim was not filed for these services within the required time limit. Therefore, we decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection of substance into lower spine 
canal using imaging guidance, insertion of programmable spinal canal drug infusion pump, and 4 of electronic 
analysis and reprogramming of spinal canal drug infusion pump provided on March 8, 2022, to June 23, 2022. 
 
You asked the Plan to waive the copayment for injection of substance into lower spine canal using imaging 
guidance, insertion of programmable spinal canal drug infusion pump, and 4 of electronic analysis and 
reprogramming of spinal canal drug infusion pump. You say that you are disputing the share cost. 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 $250 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. There were 5 visits, resulting in a total copayment amount of $1,250. 
 
You have been asked to pay $1,250 copayment for injection of substance into lower spine canal using imaging 
guidance, insertion of programmable spinal canal drug infusion pump, and 4 of electronic analysis and 
reprogramming of spinal canal drug infusion pump. This item/service falls within the outpatient surgery and 
other medical 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 injection of substance into lower spine canal 
using imaging guidance, insertion of programmable spinal canal drug infusion pump, and 4 of electronic 
analysis and reprogramming of spinal canal drug infusion pump provided on March 8, 2022, to June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's 
medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules are 
not satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for oncology (breast), MRNA, microarray 
genetic expression provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for oncology (breast), MRNA, microarray genetic expression. You 
say that you are disputing the share cost. 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 diagnostic tests and therapeutic services and supplies. The allowed amount of this 
oncology total $3,873, resulting in a coinsurance amount of $774.60. 
 
You have been asked to pay 20% coinsurance for oncology (breast), MRNA, microarray genetic expression. 
This item/service falls 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 oncology (breast), MRNA, microarray genetic 
expression provided on March 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on July 31, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are disputing the share cost. 
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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for emergency care. This item/service falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July 
31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on July 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that things happen, and you have to go to a dentist. 
You say you should not have to pay for this service. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested limited oral evaluation (D0140) but is limited to one procedure per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested limited oral evaluation (D0140) was exhausted on date of service March 
5, 2022. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided 
on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided by a participating provider on July 21, 2022. 
 
You asked the Plan to pay for local anesthesia. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided by a participating provider 
on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that bilevel positive airway pressure (BiPAP) was tried 
and failed. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this purpose 
and there is no evidence to suggest failure of BiPAP. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the portable oxygen concentrator provided on January 12, 2022.
You asked the Plan to provide additional reimbursement for the portable oxygen concentrator. You say that you should be reimbursed more. The Plan denied your request. The Plan says that the coinsurance applied is correct.
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the enrollee. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Specifically, the record indicates that the Plan has paid the Medicare allowed amount for this service less the applicable coinsurance.
A Medicare provider should accept the Medicare allowed amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare allowed payment. Therefore, we decided that the Plan does not have to provide additional reimbursement for the portable oxygen concentrator provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for injections provided on July 22, 2021 billed under code 64493.
You asked the Plan to pay for code 64493. You say that this claim should be paid. The Plan denied your request. The Plan says code 64494 was previously paid however code 64493 has created a billing error on the claim. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided documentation to show code 64494 was paid and explained the error created by code 64493. The Plan demonstrated that a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 64493 and 99214. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed by the provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifiers. In this case, code 64493 could not be paid as billed due to the omission of the required modifier. Medicare rules for coverage of code 64493Therefore, we decided that the Plan does not have to pay for injections provided to the enrollee on July 22, 2021, and billed under codes 64493.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the pertuzumab (J9306), and 
Trastuzumab (Q5116) provided on May 20, 2022. 
 
You asked the Plan to pay an additional amount for the chemotherapy drugs. You say that the drugs were 
processed at the out-of-network rate. You also say that the provider was surely in-network. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the chemotherapy services received in-network. These 
services fall 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. The record shows that the Medicare allowed 
amounts for these drugs are $11,387.04 and $2,703.85, thus the in-network coinsurance was applied correctly. Therefore, we decided that the Plan does not have to pay an additional amount for the pertuzumab (J9306), and 
Trastuzumab (Q5116) provided on May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve atezolizumab (Tecentriq) and bevacizumab-bvzr (Zirabev) for the enrollee.
You asked the Plan to pre-approve Tecentriq and Zirabev. You say that the requested regimen is medically necessary for the enrollee. The Plan denied your request. The Plan says that the requested treatment is not in the order consistent with your health plan policy.
Our Medical director looked at the case file and the reopen request. At issue is coverage for Tecentriq and Zirabev. Our Medical Director states that there is insufficient evidence in the compendia and in the medical literature to support the treatment of previously treated metastatic hepatocellular carcinoma with atezolizumab and bevacizumab. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Tecentriq and Zirabev.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq and Zirabev have not been met. Therefore, we decided that the Plan does not have to pre-approve atezolizumab (Tecentriq) and bevacizumab-bvzr (Zirabev) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 3, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee is in a nursing home and does not 
have an option on what laboratory service to use. The Plan denied your request. The Plan says the enrollee 
must receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 3, 2022, 
by an OON provider.