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

We decided that the Plan does not have to provide coverage for a vertical shock reducing pylon feature (L5988)
and flexible protective outer surface covering system (L5964).

You asked the Plan to provide coverage for these prosthetic items. You say that at the time of the appeal, these
prosthetic accessories were medically necessary. The Plan denied your request. The Plan says the Medicare
coverage criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria. Maximus upheld the flexible protective outer surface
covering system (L5964) in agreement with the Plan. Regarding the vertical shock reducing pylon feature
(L5988), the Plan noted the medical records provided do now explain why you require this accessory.
The medical records state you wish to return to bowling and riding a bicycle which are activities that can be
accomplished with the previously provided components. The medical records do also do not show you
physically require extra shock absorption which the pylon is typically needed for.

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 does not cover accessories that exceed
medical need. Medicare requires the medical records show demonstrate a clear need for the accessories
requested. Based on the medical records provided, the documentation does not support the need for a vertical
shock reducing pylon feature (L5988).

As stated in the prior decision for the protective covering, there is no justification or context found in the record
to suggest that your prosthesis will be exposed to unusually harsh environments necessitating additional
protection beyond what is provided with a typical cover. Therefore, we decided that the Plan does not have to
provide coverage for a vertical shock reducing pylon feature (L5988) and flexible protective outer surface
covering system (L5964).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on July 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an ultrasound. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an ultrasound provided on July 5, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluations provided on June 19, 2023, to 
August 10, 2023. 
 
You asked the Plan to pay for the home visit evaluations. You say that you are requesting reconsideration of 
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 the home visit 
evaluations provided on June 19, 2023, to August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on December 22, 2022. 
 
You asked the Plan to pay for podiatry services. 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 podiatry services 
provided on December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
June 26, 2023, to June 29, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost share is 
wrong. 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 $195 
copayment for inpatient hospital services. 
 
You have been asked to pay a $195 copayment for the inpatient hospital services. This item/service falls within 
the inpatient 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. You have been asked to pay a $585 copayment for the inpatient hospital stay ($195 x 3 
days). You have not been charged for the day of discharge. Therefore, we decided that the Plan does not have 
to waive the copayment for the inpatient hospital services provided on June 26, 2023, to June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on June 
12, 2023. 
 
You asked the Plan to waive the copayment for the office visit (99213). You say that the cost share is wrong. 
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 $10 
copayment for Physician/Practitioner Services, Including Doctors Office Visits. 
 
You have been asked to pay a $10 copayment for the office visit (99213). This item/service 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 (99213) provided on June 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 2, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that the records support the medical necessity of 
the claim. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97010, 97014, 97035, 97140, and 97530 for 
date of service June 28, 2023. 
 
You asked the Plan to pay for procedure codes 97010, 97014, 97035, 97140, and 97530. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that S39.012A (Strain of muscle, fascia and tendon of lower back, initial 
encounter) has an Excludes1 note in relation to M54.51 (Vertebrogenic lowback pain). This means that the two 
diagnosis codes cannot be reported together. This means codes 97035, 97140, and 97530 are not payable as 
billed. We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 97010 is not separately payable. We find that procedure code 97014 has a Status 
Indicator of I on the Physician Fee Schedule. This means that procedure code 97014 is not valid for Medicare 
purposes. Based on this information, we decided that the Medicare billing rules for procedure codes 97010, 
97014, 97035, 97140, and 97530 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 97010, 97014, 97035, 97140, and 97530 for date of service June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyaluronan (J7327) and arthrocentesis (20611) provided 
on August 22, 2023. 
 
You asked the Plan to pay for the hyaluronan (J7327) and arthrocentesis (20611). You say that the services 
were medically necessary. 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 the hyaluronan (J7327) 
and arthrocentesis (20611) provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology visit provided on March 31, 
2023. 
 
You asked the Plan to waive the copayment for a cardiology visit. You say that you were not aware that you 
had a copayment for this provider, as youve never had to pay one before. 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a cardiology visit. This item/service 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 a cardiology visit provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a therapeutic injection, provided on 
September 15, 2023. 
 
You asked the Plan to waive the coinsurance for a therapeutic injection,. You say that you feel you were given 
the wrong information and therefore, you should not have to pay. 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 Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for a therapeutic injection,. This item/service falls within the 
Medicare Part B drugs 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 $49.82 ($249.12 x 20% = $49.82). Therefore, we decided that the 
Plan does not have to waive the coinsurance for a therapeutic injection, provided on September 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that you need the requested item. The Plan 
denied your request. The Plan says this item is noncovered. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as 
noncovered, since it does not meet the definition of a prosthesis.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a mastectomy sleeve have not been met. Specifically, the mastectomy sleeve does not meet the 
definition of a prosthesis and is not covered by the Plan. Therefore, we decided that the Plan does not have to 
pre-approve a breast prosthesis, mastectomy sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that you need a lightweight folding 
transport wheelchair because you are unable to get into the restroom in your home. You also say you need the 
custom wheelchair to use when you leave the home. The Plan denied your request. The Plan says this is a 
convenience item, which is not covered by the Plan or Medicare. Duplicate items are not a covered benefit. 
 
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 received an ultralightweight wheelchair in March 2023. An ultralightweight wheelchair 
serves the same purpose as a lightweight wheelchair. Therefore, we decided that the Plan does not have to pre-
approve a lightweight wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 07, 
2023. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you canceled this appointment 
and should not have to pay a copay. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a specialist visit. This item/service 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 a specialist visit provided on August 07, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for an Ultraviolet light therapy system (E0691) provided on August 25, 
2023. 
 
You asked the Plan to pay for an Ultraviolet light therapy system (E0691). You say that the Ultraviolet light 
therapy system provided was medically necessary. The Plan denied your request. The Plan says that the 
enrollee did not meet criteria for the Ultraviolet light therapy system provided.  
 
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 pay for an Ultraviolet light therapy system (E0691). 
Our reviewer says that the enrollee did meet criteria for the Ultraviolet light therapy system provided.  Our 
physician reviewer found according to the medical record, the enrollee has psoriasis, which justifies the need 
for the Ultraviolet light therapy system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Ultraviolet light therapy system (E0691) have been met. Therefore, we 
decided that the Plan has to pay for an Ultraviolet light therapy system (E0691) provided on August 25, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
April 18, 2023, to April 27, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost share is 
wrong. 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 $370 
copayment for inpatient hospital care.. 
 
You have been asked to pay a $370 copayment for the inpatient hospital services. This item/service 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. You must pay a $1850 copayment ($370 x 5 days). You were not charged for days 6-9. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services 
provided on April 18, 2023, to April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee was admitted with pneumonia 
and tolerated initial bilevel positive airway pressure (BIPAP), but then refused while in the house. The enrollee 
would likely benefit from BIPAP with or without average volume-assured pressure support (AVAPS) as initial 
therapy. There is no documented failure of BIPAP. Hence, there is no indication for a home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the nivolumab injection provided on 
September 13, 2023. 
 
You asked the Plan to reduce the coinsurance for the nivolumab injection. You say that you cannot afford the 
injection. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the nivolumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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 amount you owe is $14,619.36 allowed amount x 20% = $2,923.87 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the nivolumab injection 
provided on September 13, 2023.