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

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on October 14, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on October 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray of the foot you had at an 
outpatient hospital facility on November 4, 2021. 
 
You asked the Plan to waive the copayment for the x-ray of the foot. You say that you had this x-ray at an 
urgent care center, so your copayment should only be $35. The Plan denied your request. The Plan says you 
were charged this copayment correctly.  The Plan says that because the allowed amount for this service 
($76.72) is less than your copayment obligation, you are responsible for the full allowed amount for this 
service. 
 
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 $95 
copayment for basic radiological services at an outpatient hospital.  
 You have been asked to pay a $95 copayment for the x-ray of the foot. The facility where you received this x-
ray bills as an outpatient hospital, not as an urgent care center.  That is why the x-ray of the foot falls within the 
basic radiological services at an outpatient hospital 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 x-ray of the foot you had at an outpatient hospital facility on November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that there was no indication that the patient 
could not participate in treatment at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you would improve in a reasonable period of time as you were not showing any dangerousness to 
self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute 
threats of safety. You were cooperative and compliant with medication. There was no mention of alcohol 
withdrawal symptoms in the documentation. It does not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have 
any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician 
reviewer found that your condition does not meet criteria for coverage of inpatient psychiatric hospital services. 
 
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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in the home with home health care or in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the compound drug solution (Bupiv, 
Clonid, and Morphine) that you received from February 11, 2021, to October 20, 2021. 
 
You asked the Plan to waive the coinsurance for the compound drug solution. You say that this drug was 
approved by the Plan, so it should be covered 100%. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 Medicare Part B drugs.  
 
 
  
You have been asked to pay 20% coinsurance for the compound drug solution. The compound drug solution 
falls within the Medicare 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 to waive the coinsurance for 
the compound drug solution (Bupiv, Clonid, and Morphine) that you received from February 11, 2021, to 
October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes A4253 and A4259 provided on June 14, 2021. 
 
You asked the Plan to pay for procedure codes A4253 and A4259. You say that the Plan did not explain why 
these codes were bundled and not paid. The Plan denied your request. The Plan says that because these two 
codes have a status indicator of 'P', no separate payment is made for them. 
 
The Plan must follow Medicare rules. Medicare rules say that that if a service is billed under the Medicare 
Physician Fee Schedule, and the code has a status indicator of 'P', then no separate payment is made for them 
under the physician fee schedule.  If the item or service is covered as other than incident to a physician's 
service, it is excluded from the physician fee schedule, and is paid under other payment provisions. 
 
In this case, it appears as though the Plan is improperly applying Physician Fee Schedule rules to a Durable 
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provider.  The procedure codes denied 
represent DMEPOS services that would be paid under the DMEPOS fee schedule, NOT the Medicare 
Physician Fee Schedule.  The rule cited above confirms that separate payment is not made under the Physician 
Fee Schedule for these codes.  However, the rule also confirms that if the items were provided as NOT incident 
to a physician service (which appears to be the case here), then payment may be made under other payment 
provisions (such as the DMEPOS fee schedule).  We find that the Plan erred in not considering payment for 
these codes under the DMEPOS fee schedule, as the status indicator of P only precludes payment under the 
Physician Fee Schedule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes A4253 and A4259 have been met. Therefore, we decided that the Plan has to pay 
for procedure codes A4253 and A4259 provided on June 14, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on October 12, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you believe the trip 
was unnecessary and the enrollee should not be responsible for the copayment. The Plan denied your request. 
The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $160 copayment for each one-way ambulance trip.  
 
The enrollee has been asked to pay a $160 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for ambulance transportation services provided on October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043) rendered by 
the out-of-network (OON) provider on November 2, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the muscle and/or fascia debridement (11043) rendered by the out-of-network (OON) 
provider on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for progressive lenses provided on  
September 29, 2021. 
 
You asked the Plan to reimburse you for the progressive lenses. The Plan denied your request. The Plan says 
progressive lenses, no-line bifocal or trifocal lenses, tinting (except for certain ultraviolet screening coatings), 
scratch-resistant coatings, or oversized lenses are not covered unless required by Medicare coverage guidelines. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that 
includes insertion of an intraocular lens (If you have two separate cataract operations, you cannot reserve the 
benefit after the first surgery and purchase two eyeglasses after the second surgery.). Progressive lenses, no-
line bifocal or trifocal lenses, tinting (except for certain ultraviolet-screening coatings), scratch-resistant 
coatings, or oversized lenses are not covered unless required by Medicare coverage guidelines. 
 
We looked at the file, the Medicare rules and the Plan's rules. The file shows that the progressive lenses were 
purchased due to cataract surgery. The Plan and Medicare do not cover progressive lenses. Therefore, we 
decided that the Plan does not have to reimburse you for progressive lenses provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Caresens N strips and Caresens control solution, and 
Sterilance lancing device and Sterilance Twist Top lancets, provided on January 13, 2021. 
 
You asked the Plan to pay for the diabetic supplies. You say that the items should be covered. The Plan denied 
your request. The Plan says this is not the preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic supplies have not been met. Specifically, there is no evidence that the items received 
are medically necessary over the Plan's preferred brands. Therefore, we decided that the Plan does not have to 
pay for Caresens N strips and Caresens control solution, and Sterilance lancing device and Sterilance Twist 
Top lancets, provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on July 31, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that the item should be covered. The Plan denied your 
request. The Plan says the claim was filed untimely. 
 
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 claim for the hearing aids was not filed until August 26, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the hearing aids provided on July 31, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan of extremity veins including 
responses to compression and other maneuvers (93970) rendered on September 1, 2021. 
 
You asked the Plan to waive the copayment for a duplex scan of extremity veins including responses to 
compression and other maneuvers. You say that you were not asked or told what you were paying, and you 
believe they collected $35, so you are a bit confused. You also say that you do not work so this is totally out of 
your reach. The Plan denied your request. The Plan says you were 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 a $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). Your contract with 
the Plan also says that the diagnostic radiology services require specialized equipment beyond standard x-ray 
equipment and must be performed by specially trained or certified personnel, which includes, but not is limited 
to ultrasounds.  
 
You have been asked to pay a $110 copayment for a duplex scan of extremity veins including responses to 
compression and other maneuvers. A duplex scan of extremity veins including responses to compression and 
other maneuvers 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 a duplex scan of extremity veins including 
responses to compression and other maneuvers (93970) rendered on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and bitewing x-rays (D0272) 
provided on June 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that the provider was out 
of network. You also say that you are not happy with the billing issue. The Plan denied your request. The Plan 
says dental services received out of network are not covered. 
 
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. The record shows that the provider's contract did not become effective 
with the Plan until November 11, 2021. Therefore, we decided that the Plan does not have to pay for the oral 
exam (D0120) and bitewing x-rays (D0272) provided on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services for an excision of malignant lesion 
(11606) provided on October 20, 2021. 
 
You asked the Plan to pay for assistant surgeon services. You say that assistant surgeon services were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for assistant 
surgeon services have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 11606. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure.  
 This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid. Based upon this information, we find that Medicare coverage criteria for assistant surgeon services have 
not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services for an 
excision of malignant lesion (11606) provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cytopathology, cervical or vaginal (88142) provided on 
November 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a cytopathology, cervical or vaginal. You say that you do not see patients and 
you do not have access to the patient's insurance information. You also say that as third-party providers you are 
not required to get an authorization. The Plan denied your request. The Plan says it was determined that the 
rendering provider is non-participating and there is not a referring provider. The Plan also says that there is no 
evidence that this is urgent or emergent. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a cytopathology, cervical or vaginal (88142) 
provided on November 9, 2021, 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 an inpatient hospital stay provided from 
November 1, 2021, to November 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have to 
pay the copayment because the doctor made a mistake which caused you to stay longer in the hospital. The 
Plan denied your request. The Plan says the proper copayment 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 $200 
copayment for an inpatient hospital stay per day for days 1 to 6. The total amount charged for copayment was 
$1200 ($200 copayment x 6 days). 
 
  You have been asked to pay a $1200 copayment for the inpatient hospital stay. 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 copayment for 
an inpatient hospital stay provided from November 1, 2021, to November 11, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.