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

 
We decided that the Plan does not have to pay for lab services provided on November 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from January 3, 2022, to January 9, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not 
have to pay this copayment because you had to be readmitted since you were discharged prematurely without 
antibiotics for an infection.  You said that the hospital told you that you would not have to pay a copayment for 
the readmission. The Plan denied your request. The Plan says you were charged this copayment 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 $335 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $335 copayment per day for days 1-6 for the inpatient hospital services. This 
copayment applies each time you are admitted. 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 services you received from January 3, 2022, to January 9, 2022.  Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 14, 2022. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says after three or 
more attempts to obtain documentation of a current order, none was received as of this time. 
 
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 psychotherapy provided on  
March 14, 2022 have been met. Therefore, we decided that the Plan does not have to pay for psychotherapy 
provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) and a wound 
care set. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that an NPWT pump and supplies are denied when 4 
months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have 
elapsed using a NPWT pump in the treatment of the most recent wound. 
 
We looked at the file and Medicare rules. The fiel shows that four months have elapsed since you began using 
the NPWT pump. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve negative pressure wound 
therapy (NPWT) and a wound care set.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that this is necessary. The Plan denied your 
request. The Plan says that you received a power scooter five months ago. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power scooter. a power scooter serves the same purpose as a power scooter. 
Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.   
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 pay for the services provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on June 7, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tracheostomy supplies to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that these services are available with a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
Tracheostomy supplies to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for neurologist appointments. The Plan denied your request. The Plan says that this request exceeds the benefit 
limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to cover routine transportation above the benefit maximum of twenty-four routine 
transportation trips. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 24, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $50 
copayment for Physician/Practitioner services, including doctors office visits, specifically specialist visits.  
 
 
  You have been asked to pay a $50 copayment for the specialist office visit. Specialist office visits fall 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 a specialist office visit provided on February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
face provided on February 15, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you feel the scan should have been 
done during your ER visit. 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 $225 
copayment for advanced imaging services, including CT scans.  
 
You have been asked to pay $106.62, which is less than the $225 copayment for the CT scan. The CT scan 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 computed tomography (CT) scan of the face provided on February 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens, scleral, gas permeable, per lens (V2531) 
provided February 24, 2022. 
 
You asked the Plan to pay for the scleral contact lenses. You say that these contact lenses are medically 
necessary. The Plan denied your request. The Plan says the scleral contacts are not covered for your diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that covered diagnoses for refractive lenses are 
limited to pseudophakia, aphakia, and congenital aphakia. 
 
We looked at the file and Medicare rules. In this case the scleral contact lenses are being prescribed for 
keratoconus. Based on this information, we decided that Medicare rules for coverage of the scleral contact 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact lens, scleral, 
gas permeable, per lens (V2531) provided February 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the eye exams provided from February 10, 2022, to 
February 24, 2022. 
 
You asked the Plan to waive the copayment for eye exams. You say that you should not have a copayment for 
these visits. The Plan denied your request. The Plan says that there is no copayment for each Medicare-covered 
exam to diagnose and treat diseases or conditions of the eye. 
 
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 do not have a copayment for Medicare-covered Vision Care.  
 
The Plan says you must pay a $90 copayment for eye exams. Based on the Plan contract, however, you cannot 
be asked to pay more than $0 for eye exams. Therefore, we decided that the Plan has to waive the copayment 
for the eye exams provided from February 10, 2022, to February 24, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services from December 
16, 2021 to February 10, 2022. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you are dissatisfied 
with the quality of care received. You say you would like to be reimbursed for payments made and any 
payments pending.  The Plan denied your request. The Plan says you have been charged the correct copayment 
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 $25 
copayment for each covered physical and speech therapy visit.  
 
 Covered services include physical therapy, occupational therapy, and speech language therapy. Outpatient 
rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, 
independent therapist offices, and comprehensive outpatient rehabilitation facilities (CORFs). Prior 
authorization may apply.  
 
You have been asked to pay a total of $150 ($25 x 6 visits = $150). Physical therapy services fall within the 
Outpatient Rehabilitation 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 
physical therapy services from December 16, 2021 to February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (77002, 97014) provided on January 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
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 code 77002 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. 
 
We also find that CPT code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that 
CPT code 97014 is not valid for Medicare purposes. 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 pay for the 
services (77002, 97014) provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blind cane with support (white cane). 
 
You asked the Plan to pre-approve a blind cane with support. You say that you cannot stand without a cane. 
The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that white cane for a blind person is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a blind cane with support have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a blind cane with support (white cane).
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 the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not document those services in the home with home health care or in a long-term 
care facility on a part time basis are not 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (MILD). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MILD/PILD is covered for enrollees in an 
approved clinical study. 
 
We looked at the file and Medicare rules. The file shows that the enrollee is not in an approved clinical study 
for the requested procedure. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally 
invasive lumbar decompression (MILD).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 fractions of Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve 5 fractions of SBRT. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 5 fractions of SBRT. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have had prior metastatic disease; though in you this was limited to one nodal site of 
disease that is controlled and based on the ASTRO/ESTRO consensus this scenario would not be outside the 
diagnosis of oligometastases. As the treatment appears to be in accordance with accepted standards of care, the 
treatment is medically necessary and 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 5 fractions of SBRT have been met. Therefore, we decided that the Plan has to 
pre-approve 5 fractions of Stereotactic Body Radiation Therapy (SBRT).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire syringe. 
 
You asked the Plan to pre-approve Tezspire syringe. 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 Tezspire syringe. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the Plan requires a trial of drug 
Xolair before they will approve the requested drug.In this case, you have not tried and failed the required 
drug(s). There is no documentation provided indicating that the plans required drug(s) would likely be less 
effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tezspire syringe have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Tezspire syringe.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99284) provided on July 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 pay for the services (99284) provided on July 18, 2021.