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

 
We decided that the Plan does not have to waive the coinsurance for oxygen concentrator on January 14, 2021, 
to June 14, 2021. 
 
You asked the Plan to waive the coinsurance for oxygen concentrator. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance of the cost for Medicare-covered durable medical equipment and related supplies. 
Covered items include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic 
supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, speech generating 
devices, oxygen equipment, nebulizers, and walkers. The provider billed in the amount of $410 and the allowed 
amount is $180.92. The Plan paid $144.74. $180.92 x 20% = $36.18. There were 6 dates of service.  $36.18 x 6 
= $217.08. Therefore, results in the total cost sharing amount of $217.08. 
 The enrollee has been asked to pay a 20% coinsurance for oxygen concentrator. Oxygen concentrator falls 
within the Durable medical equipment (DME) and related supplies 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 coinsurance for oxygen concentrator on January 14, 2021, to June 14, 2021.
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 
March 13, 2022, to March 20, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have already paid 
$1,170 for a previous hospital stay. You say that you should not be billed twice for the first 6 days of 
hospitalization. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 
copayment per day for days 1 to 6 and $0 copayment per day for days 7 to 90 for inpatient hospital care. The 
Plan contract also says the inpatient cost share will begin on day one each time you are admitted or transferred 
to a specific facility type.  
 
 You have been asked to pay a $195 copayment per day for days 1 to 6 of your 8-day hospital stay, for a total of 
$1,170 ($195 x 6). 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 March 13, 2022, to 
March 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the doctor was very rude, he 
walked out and did not even see you. He told you to see someone else. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-person specialist visit.  
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for chiropractic services. You say that you have already paid a 
copayment to see this provider and do not feel you should have to pay another. The Plan denied your request. 
The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for chiropractic services.  
 
You have been asked to pay a $20 copayment for chiropractic services. Chiropractic services fall within the 
Chiropractic 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 chiropractic 
services provided on April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 24, 2022, to February 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were hospitalized with 
COVID-19 complications and cannot afford the copayment. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $295 per 
day for days 1-7 and $0 per day for days 8-90 for each inpatient admission.  
 
The file shows that you were in the hospital from January 24, 2022, to February 7, 2022. Therefore, you have 
been asked to pay $295 per day for days 1-7 of inpatient care. The total for your stay is $2,065 ($295 
copayment x 7 days = $2,065). The inpatient care 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 inpatient hospital care provided from January 24, 2022, to 
February 7, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided to the enrollee on June 14, 2021, under codes 95870, G0453 and 95938.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans denial for insufficient billing guidelines in the case file. The Plan requested a reopen and provided the required Medicare guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare has specific guidelines for the billing of these codes. The services billed are not supported by the limited records provided. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for diagnostic services provided to the enrollee on June 14, 2021, under codes 95870, G0453 and 95938.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for surgery services provided to the enrollee on January 26, 2021,
separately billed under codes 64447 and 64450.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says codes 64447 and 64450 are included in the payment of code 01480 and
cannot be separately billed. Maximus administratively overturned the Plans denial because proof of payment
for code 01480 for the same date of service was not provided in the case file. The Plan requested a reopen and
provided a copy of the paid claim for code 01480 for the same date of service.
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. In this case, because codes
64447 and 64450 are included in the payment of code 01480, they cannot be separately billable. Based on this
information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we
decided that the Plan does not have to pay for surgery services provided to the enrollee on January 26, 2021,
under codes 64447 and 64450.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the removal of extra skin and tissue of 
abdomen provided on January 31, 2022. 
 
You asked the Plan to waive the cost share for the excision. You say that when you call the Plan to see if the 
doctor was in-network you were told he was. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance after your $750 deductible for an outpatient surgery.  
 
You have been asked to pay a 40% coinsurance after your $750 deductible for an outpatient surgery for a total 
of $462.58. The excision 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 cost share for the removal of extra skin and tissue of abdomen provided on January 
31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity, any joint to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the upper extremity, any joint. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the facility chosen is not in network with 
your Plan. The Plan also says that there are facilities available in the member's network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a magnetic resonance imaging (MRI) of the upper extremity, any joint to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6549, 
S8421, and A4465. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items 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 compression stockings described by codes A6549, 
S8421, and A4465 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with codes A6549, S8421, and A4465.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical fusion for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the criteria for fusion is not met. More conservative measures, including physical therapy, are 
needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical fusion for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87798, 87481) provided August 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of lab services (87150, 87798, 87481) 
provided August 3, 2021. have been met. No medical records were provided to support the billed service. Therefore, we decided that the Plan does not have to pay for lab services (87150, 87798, 87481) provided 
August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80061, 83036, 84443, 80053) provided January 
25, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim was not filed timely. 
 
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 lab services was not filed until April 14, 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 lab services (80061, 83036, 84443, 80053) provided January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided October 21, 
2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a continuous glucose monitor (K0553) provided October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services billed to the enrollee for November 18, 2021, under code 64999.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient medical records. The Plan requested a reopen and stated this was not a medical necessity issue and was reviewed for a coding issued. The Plan states that the claim has coding discrepancies based on the Medicare billing guidelines. The Plan noted the denial of the 79 modifier is due to the unlisted procedure code billed. The Plan states per the coding guidelines, CPT 64999 is not the appropriate code to bill for left endoscopic ulnar nerve decompression. The Plan demonstrated the March 2009 edition of CPT Assistant advised that it would be correct to report the procedure using code 29999 (Unlisted procedure, arthroscopy). The Plan states while code 64718 describes an open cubital tunnel release, there is no specific code to describe endoscopic cubital tunnel release. The Plan states the Medicare guidelines note it is not appropriate to report open surgical procedure code 64718 or 64719 for an endoscopic procedure as it is not acceptable to report a code for a procedure that is only similar to the actual procedure performed. Instead, code 29999 for "Unlisted procedure, arthroscopy," should be reported to follow Medicare coding guidelines.
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. In this case this claim cannot be paid as billed due to a discrepancy between the definition of the codes billed and the actual services provided. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for surgical services billed to the enrollee for November 18, 2021, under code 64999.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the $76 charged for vision wear and lenses provided on October 20, 2021.
You asked the Plan to waive this cost share. You say that this cost share should be covered by the Plan., The Plan denied your request. The Plan says this cost share was applied correcly. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan shows the claim processed with a $76 cost share liability. The vision provider charged $395 for this eyewear. The Evidence of Coverage shows a $300 benefit toward the purchase and fitting of eyeglasses & pair of lenses at a network optical provider, which is allowed once per calendar year. You were charged less than the remaining $95 that the benefit does not cover due to the additional contractual discounts that were applied by the vision plan holder. The case file includes the Explanation of Benefits that shows the vision plan holder paid $180 to the vision provider and discounted the amount of $139. Any balance owed at that point would be your responsibility.
The Plan is correct in this case. 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 after the $300 vision benefit is applies, any remaining cost is your responsibility. 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 $76 charged for vision wear and lenses provided on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nerve stimulator (E0730) provided April 7, 2022. 
 
You asked the Plan to pay for the nerve stimulator. You say that the device was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a nerve stimulator (E0730) provided April 7, 2022.