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

We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS).
You asked the Plan to pre-approve Transcranial Magnetic Stimulation (TMS). You say that this treatment 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 follow the
LCD criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Transcranial
Magnetic Stimulation (TMS). The Maximus Physician Reviewer determined that the enrollee meets criteria for
the requested Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment. The Plan notes that the
records show a response to treatment with Ketamine, with increased level of social interaction. The Plan also
notes there is not current treatment with a psychotherapist.
The medical records show a diagnosis of Major depressive disorder, recurrent severe without psychotic
features. The Psychiatric Re-Evaluation note dated June 8, 2021 documents "the patient actually responded to
her treatment yesterday with an increased level of activity and more social interaction with her friends." It is
also documented that the "patient is not currently involved with a psychotherapist at this time." Under the
heading Treatment, it is states that "The patient was provided with supportive psychotherapy, psychoeducation,
and medication management in the context of this visit."
The Plan is correct in this case. The clinical documentation does not support that a resistance to treatment as
evidenced by a lack of clinically significant response to 4 trials of psychopharmacologic agents in the current
depressive episode. On the contrary, it is documented that there has been a response to treatment in the current
depressive episode. 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 Transcranial Magnetic Stimulation (TMS) have not been met. Therefore, we
decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Sanexas treatment provided on May 17, 2021. 
 
You asked the Plan to pay for Sanexas treatment. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because these 
services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for outpatient physical therapy 
services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; 
or by, or incident to the services of a nurse practitioner (NP) or physician assistant (PA) only when that 
practitioner may perform services under state law. Medicare rules say that compounded drugs shall be 
submitted using a compounded drug, not otherwise classified code. 
 We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the 
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide 
physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled 
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not 
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. 
Because the drugs are not paid as billed, the drug administration codes also cannot be paid. Based on this 
information, we decided that Medicare rules for coverage of Sanexas treatment have not been met. Therefore, 
we decided that the Plan does not have to pay for Sanexas treatment provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on June 22, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that you received these lab services 
during your annual wellness visit.  You said that you were told the wellness visit was covered in full. The Plan 
denied your request. The Plan says the cost for lab services in not included in your annual wellness visit, so 
your copayment 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 lab services.  
 
You have been asked to pay a $20 copayment for the lab services. Your contract explicitly states that the annual physical and annual wellness exams do not include lab services.  The contract says that additional cost 
sharing applies for lab services. 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 lab services you received 
on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on October 31, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the services were medically necessary. 
 The Plan denied your request. The Plan says although the claim originally denied for an experimental 
procedure, Medicare non-coverage, and a missing diagnosis, however, there was no prior authorization 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on October 31, 2020, 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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on July 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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the cardiology visit you had on April 14, 
2021. 
 
You asked the Plan to waive the deductible for the cardiology visit. You say that you believe the claim was 
denied because the office visit lasted an excessive amount of time.  You believe the claim should be paid. The 
Plan denied your request. The Plan says the claim was note denied.  Rather, the you had not met your 
deductible at the time of the services, so you are responsible for the full allowed amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $203 deductible which applies to specialist services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which 
applies to specialist services. This cost sharing is a contractual obligation that had not been met at the time the 
cardiology visit was received on April 14, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for the cardiology visit you had on April 14, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the copayment charged for skilled nursing facility (SNF) services you 
received from July 1, 2021, to July 10, 2021. 
 
You asked the Plan to waive the copayment charged for the SNF services. You say that you do not believe you 
were provided with adequate notice of what the plan would cover. The Plan denied your request. The Plan says 
that you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for days 1-20, and a $184 copayment per 
day for days 21-100 for skilled nursing facility care.  
 
The Plan says you must pay a $184 copayment per day for the SNF services. We do not agree.  The records 
indicate that you were admitted to the SNF on June 29, 2021, and discharged on July 10, 2021, for a total of 12 
days.  According to your contract, you pay a $0 copayment for days 1-20, so this 12-day period would have all 
fallen in this $0-copayment period. The Plan has failed to provide any evidence of any previous SNF stay 
within the benefit period that would have changed how the covered days were calculated.  Based on the Plan 
contract, you cannot be asked to pay more than a $0 copayment for days 1-20.  The dates of service in question 
are all within the first 20 days of the SNF stay. Therefore, we decided that the Plan has to waive the copayment 
charged for skilled nursing facility (SNF) services you received from July 1, 2021, to July 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on May 14, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the services were medically necessary. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work 
provided on May 14, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on July 12, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services represented by codes 88341 and 88342 provided on May 24, 2021.

You asked the Plan to pay for codes 88341 and 88342. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 codes 88341 and 88342 are column II codes to column I code 88360. 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 the laboratory services represented by codes 88341 and 88342 provided on May 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the edema compression strapping 
procedures you had at an outpatient hospital from March 26, 2021, to April 23, 2021. 
 
You asked the Plan to waive the copayments for the strapping procedures. You say that you are on a fixed 
income and cannot afford these copayments. The Plan denied your request. The Plan says you were charged 
these copayments correctly.  The Plan says that because the allowed amount for each service ($200.64) is less 
than your copayment obligation, you are responsible for the full allowed 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 $250 
copayment for outpatient procedures at an outpatient hospital.  
 
 You have been asked to pay a $250 copayment for the strapping procedures. The strapping procedures fall 
within the outpatient procedures 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 copayments for the edema compression strapping procedures you had at an outpatient hospital 
from March 26, 2021, to April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that you cannot stand up in shower without having to sit 
down and you're scared of falling. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
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 
August 14, 2020, to September 9, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not ask to be 
transferred and feel that you should not be held responsible for the charges. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct 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 $345 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from August 14, 2020, to September 9, 2020. Therefore, you are responsible 
to pay a $345 copayment for days 1-5 (August 14, 2020, to August 18, 2020). The total amount you owe is: $345 (copayment) x 5 (inpatient days) = $1,725.  
 
You have been asked to pay the total copayment amount of $1,725 for an inpatient hospital stay. An 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 August 14, 2020, to September 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 physical therapy visits and 3 skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the enrollee had an injury to the joints in 
your knee. You say that you are unable to walk without a walker. You say that you are still not strong enough 
to do everything you need to do in your daily living. You also say that occupational therapy (OT) was also 
helping to strength your core. The Plan denied your request. The Plan says the enrollee no longer requires 
skilled nursing care. The Plan also says that the enrollee's diagnoses are not eligible for physical therapy visits 
according to Medicare. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the home health services are not medically necessary. Our physician reviewer found you do not have 
documented skilled nursing needs. The reviewer found there is no explanation as to why you or your family 
cannot tend to your wounds. The reviewer found you do not have documented skilled physical therapy needs. 
Therefore, the reviewer found that the requested ongoing home health services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Specifically, the file does not show 
that you have any documented skilled nursing or skilled physical therapy needs. Therefore, we decided that the 
Plan does not have to pre-approve 13 physical therapy visits and 3 skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120). 
 
You asked the Plan to pre-approve a periodic oral evaluation. You say that the services are necessary. The Plan 
denied your request. The Plan says you are not covered for this service when seen by an out-of-network 
provider. 
 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a periodic oral evaluation have not been met. Specifically, the request is for services to be provided 
out of network. The Plan has network providers available to provide the services at issue. We found no 
exception that would require the Plan to pre-approve out of network services. Therefore, we decided that the 
Plan does not have to pre-approve a periodic oral evaluation (D0120).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 3, 2020. 
 
You asked the Plan to pay for physician's services. You say that we had billed hospice for this date of service 
and was advised the patient was not enrolled at time of service. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 2, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 28, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 must 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 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 out of network physician services provided to the 
enrollee on July 28, 2021.