Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower limb prosthesis vacuum pump (L5781) and
lower extremity prostheses Flex-walk system (L5981).
You asked the Plan to pre-approve these prosthetic items. The Plan denied your request. The Plan says while
the socket was approved, the replacement foot is still covered under warranty. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the reasonable
useful lifetime of equipment in no case can be less than 5 years. The file indicates you received a prosthetic
foot in July of 2021, less than five years ago. If your current unit needs repair or replacement under warranty,
the provider must work with the manufacturer on your behalf. Therefore, we decided that the Plan does not
have to pre-approve a lower limb prosthesis vacuum pump (L5781) and lower extremity prostheses Flex-walk
system (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that your PCP was not available to follow up on your 
COVID-19 diagnosis. The Plan denied your request. The Plan says a referral/authorization was not obtained 
prior to services being rendered. 
 
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 an office visit provided on June 13, 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 office visit provided on June 30, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration because medical 
records were sent to support the medically necessity of the services. 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 you 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 office visit provided on June 30, 2022, by an out-
of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health visits provided from May 10, 2022, 
to June 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health visits. You say that you are appealing the denial of 
coverage because you were advised the provider was in-network The Plan denied your request. The Plan says 
no authorization was obtained prior to visits. 
 
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 outpatient mental health visits provided from May 
10, 2022, to June 13, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for a specialist visit, and ultrasound provided 
on January 27, 2022. 
 
You asked the Plan to reduce the copayments for a specialist visit and ultrasound. You say that you were given 
incorrect information by Plan representatives regarding coverage. You say you were reimbursed at 50% of the 
billed amount and would like to be reimbursed based on the information provided in the EOC. 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 $15 
copayment for each out-of-network specialist visit and up to a $50 copayment for each Medicare-covered 
outpatient diagnostic procedure and test in an office setting or imaging center.  
 
You have been asked to pay a total copayment of $65 for a specialist visit and ultrasound.  
 
DOS Service 
type/code 
Amount 
Billed 
Amount 
Allowed by 
Plan 
Amount 
Paid by 
Plan 
Copayment 
Per Contract 
Member 
Responsibility 
January 27, 
2022 
Specialist visit 
(99212) 
$195 $135.28 $85.28 $50 $50 
January 27, 
2022 
Unilateral 
scan (93971) 
$55 $55 $40 $15 $15 
Total  $250 $190.28 $125.28 $65 $65 
 
A specialist visit falls within the Physician/Practitioner services, including doctor's office visits, benefit 
category. An ultrasound falls within the Outpatient Diagnostic Tests 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 copayments for a specialist visit, and ultrasound provided on January 27, 2022.  
 
Your complaint about not receiving accurate information regarding coverage 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a needle biopsy provided on May 12, 2022. 
 
You asked the Plan to waive the copayment for a needle biopsy. You say that this was not a surgery, and you 
should not have this large 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 $290 
copayment for outpatient hospital services.  
 
You have been asked to pay a $290 copayment for a needle biopsy. This item/service falls within the outpatient 
hospital services 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 needle biopsy 
provided on May 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two home health aide (HHA) visits (G0156 x2). 
 
You asked the Plan to pre-approve the HHA visits. You say that you would like the HHA visits approved for 
coverage. The Plan denied your request. The Plan says these visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 HHA visits. Our reviewer says that 
the HHA visits are not reasonable and necessary. Our physician reviewer found the clinical documentation 
shows that you refused home health skilled therapy and nursing services thus there is no care plan to 
implement. Our reviewer found that there is no documented care that would require the assistance of a home 
health aide. Our physician reviewer also found that two home health aide visits are not medically necessary. 
 
 
 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 HHA visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve two home health aide (HHA) visits (G0156 x2).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 15, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on June 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want to appeal the 
amount being charged. 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 $225 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility. Covered services include, but are not limited to services in an emergency department or outpatient 
clinic, such as observation services or outpatient surgery. 
 
You have been asked to pay a $225 copayment for outpatient services. This item/service falls within the 
Outpatient hospital services 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 
services on June 28, 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 
(A0998) provided on January 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like to appeal the bill for this service. The Plan denied your request. The Plan says the ambulance was called, 
and you were not transported to an emergency facility. 
 
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 January 11, 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 (A0998) provided on January 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on October 13, 2020. 
 
You asked the Plan to pay for the rotary wing air transport and mileage. You say that you acknowledge that this 
claim submission was filed outside of the timely filing limits, but it was out of your control. You also say that 
you would still like this claim to be taken into consideration. The Plan denied your request. The Plan says these 
services are denied for untimely filing. 
 
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 rotary wing air transport and mileage was not filed until February 1, 
2022. 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 rotary wing air transport (A0431) and 
rotary wing air mileage (A0436) provided on October 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 physical therapy provided on June 30, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on May 05, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that this should be covered. 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 $48.91 
copayment for Radiation therapy services. 
 
You have been asked to pay a $48.91 copayment for CT scan. This item/service falls within the Radiation 
therapy services 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. You have been asked to pay $48.91 which is less than the standard $60 copayment for radiation therapy services. Therefore, we decided that the Plan does not have to waive the copayment for CT scan 
provided on May 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nail(s) provided on July 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for debridement of nail(s). You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  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 debridement of nail(s) provided on July 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an advanced prosthetic leg replacement to
include an L5981, all lower extremity prostheses, flex-walk system or equal and L5986, all lower extremity
prostheses, multiaxial rotation unit (MCP or equal).
You asked the Plan to provide coverage for this request. You say that this prosthetic equipment is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an advanced
prosthetic leg replacement with an L5981, all lower extremity prostheses, flex-walk system or equal and
L5986, all lower extremity prostheses, multiaxial rotation unit. The Plan requested a reopen and stated that it
disagrees with our determination. The Plan states that the vendor's claim that the enrollee is a K3 ambulator is
not supported by the medical records provided. The medical records show you are a lower extremity amputee
with an existing prosthesis with fit and function which were not satisfactory. However, the Plan is correct
regarding the flex-walk system or equal, which is covered for beneficiaries with a functional level of 3 or
above, and the axial rotational unit, which is covered for beneficiaries with a functional level of 2 or above.
The case file does not contain sufficient clinical documentation regarding your functional level. Therefore,
Medicare coverage criteria are 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 this request have not been met. Therefore, we decided that the Plan does not
have to provide coverage for an advanced prosthetic leg replacement to include the L5981, all lower extremity
prostheses, flex-walk system or equal and L5986, all lower extremity prostheses, multiaxial rotation unit (MCP
or equal).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on May 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that it was medically necessary to treat the 
enrollee without an authorization and you would like the claim processed for payment. The Plan denied your 
request. The Plan says the rendering and referring providers are both OON providers and there was no 
approved authorization. Also, the service rendered was not 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 the radiology services provided on May 2, 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 physician services provided on April 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the physician services provided on April 25, 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 a home health visit provided on April 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim paid. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not 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 home health visit provided on April 22, 2022, by 
an out-of-network (OON) provider.