Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 8, 2023, to April 
5, 2023. 
 
You asked the Plan to pay for psychotherapy services. You say that you were seeing the provider since the 
death of your husband in 2021. The Plan denied your request. The Plan says this provider is not under contract 
with the health plan and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services provided on March 8, 2023, to April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 26, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 3, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says the services 
obtained by the member were rendered by a provider who does not accept Medicare assignment. The provider 
has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on May 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
September 14, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
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 $200 
copayment for outpatient diagnostic tests/advanced radiology services. 
 
You have been asked to pay a $200 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/advanced radiology 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 diagnostic tests provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 12, 2022, and billed under code 99291 with Claim A.

You asked the Plan to pay Claim A. The Plan denied your request. The Plan says Claim A could not be paid as billed as these services were previously billed and paid under Claim B to the same provider. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided the required information. The Plan noted that Claim A denied because this service has exceeded the maximum allowed amount. The Plan provided documentation to show they previously paid for this service under Claim B for the same date of service and the same provider.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has billing limitations for this type of code. Based on the documentation provided, code 99291 was previously billed by the same provider and paid. Medicare billing criteria were not met.

Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 12, 2022, and billed under code 99291 with (Claim A).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are in-network with this plan, and this service 
should not need and authorization or a referral. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for vascular imaging provided on July 6, 2023. 
 
You asked the Plan to waive the cost for vascular imaging. You say that you disagree with the cost share 
applied because the scan was medically necessary. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and a 
$200 copayment for Medicare-covered diagnostic procedures/tests after the deductible has been met.  
 
 
  The item or service you asked the Plan to reduce the cost for falls within the outpatient diagnostic tests benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not 
been met at the time the vascular imaging was received on July 6, 2023. However, the deductible was met with 
the processing of this claim, so the Plan applied the correct copayment according to your contract with the 
Plan. Therefore, we decided that the Plan does not have to waive the cost for vascular imaging provided on July 
6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical image (D0220) provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 10, 2021. 
Therefore, we decided that the Plan does not have to pay for a periapical image (D0220) provided on June 28, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on June 20, 2023. 
 
You asked the Plan to pay for ambulance response and treatment with no transport. You say that you were not 
aware that the claim would not be covered if you were not transported to the hospital. The Plan denied your 
request. The Plan says this is a non-covered charge. 
 
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 June 20, 2023. 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 ambulance response and treatment with no 
transport provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) purchased on March 31, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that the rendering provider has trained and 
certified audiologists. You also say you are more than pleased with this provider. The Plan denied your request. 
The Plan says there is no coverage when received from a provider other than the Plan hearing network 
providers. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan network hearing provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5298) purchased on March 31, 2023.  
 Your complaint about not being satisfied with the supplemental premiums 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the home infusion therapy (HIT) services provided from April 4, 2022, through May 18, 2022.

You asked the Plan to waive the copayments for the HIT services. You say that you should not be responsible for this cost-sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial because or a lack of information. The Plan requested a reopening and provided the correct EOC.

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 Medicare-covered specialist visit. 

You have been asked to pay a $25 copayment for each date of service for the HIT services. This item/service falls within the Medicare-covered specialist visit 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 home infusion therapy (HIT) services provided from April 4, 2022, through May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids and sales tax purchased on January 19, 
2023. 
 
You asked the Plan to reimburse for hearing aids and sales tax. You say that a Plan representative informed you 
that the reimbursement forms are what is needed to take care of this matter. The Plan denied your request. The 
Plan says the hearing benefit is not covered if the services are not registered in advance. The Plan also says that 
hearing aids ordered through providers other than Plan hearing network providers are not covered. The Plan 
also says that sales tax is not medical in nature and no payment can be made. 
 
  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are registered in advance, and ordered through Plan hearing in-network 
providers.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids and sales tax have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids and sales tax purchased on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the crutches provided on July 12, 2023. 
 
You asked the Plan to waive the coinsurance for the crutches. You say that you were told the crutches would be 
free. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the crutches. This item/service falls within the durable 
medical equipment and related 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. The total you owe is $12.55 ($62.76 allowed amount x 20% coinsurance = $12.55). Therefore, we decided that the Plan does not have to waive the coinsurance for the crutches provided 
on July 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that Ondansetron is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal endoscopy provided on August 22, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the nasal endoscopy. You say that these services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that these services were not emergent because you have been seeing a network provider for these issues previously.

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 nasal endoscopy provided on August 22, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation procedure 
rendered on August 3, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of a genicular nerve radiofrequency ablation in the 
setting of chronic knee pain and osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that formal diagnostic studies are not provided for review to corroborate pathology that could benefit 
from the requested procedure. Moreover, limited published, large-scale, long-term peer-reviewed literature 
shows this request to be an effective and/or safe treatment for the noted pathology.  Further studies are needed 
to corroborate this treatment modality is as safe and effective as other standard treatments for the bilateral 
knees. No compelling rationale is presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception to guidelines. Therefore, the requested retrospective genicular nerve 
radiofrequency ablation provided on 8/3/21 is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the genicular nerve radiofrequency ablation procedure rendered on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that the 
CGM coverage criteria was met. Our physician reviewer found that the CGM was prescribed on December 4, 
2022, and the enrollee's last office visit was that day; why the prescription is being filled now 9 months later is 
not clear but this does not seem to detract from the medical necessity of the CGM. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
  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.