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

 
We decided that the Plan does not have to waive the cost share for a specialist office visit and an aflibercept 
injection provided on April 21, 2023. 
 
You asked the Plan to waive the cost share for a specialist office visit and an injection. You say that you 
disagree with the cost share. 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 $20 
copayment for each in-network specialist visit. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $20 copayment for a specialist office 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.  
 
You have also been asked to pay $370.75, which is 20% coinsurance of the allowed amount for the injection 
($1,853.76 allowed amount x 20% = $370.75). 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. 
Therefore, we decided that the Plan does not have to waive the cost share for a specialist office visit and an 
aflibercept injection provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on May 23, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the psychotherapy. You say that you are appealing the denial with supporting 
documentation. 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 the psychotherapy provided on May 23, 2023, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWODF. You say that the enrollee has a history of chronic obstructive 
pulmonary disease. You also say that it is a medical necessity and the enrollee would benefit from daily 
therapy. The Plan denied your request. The Plan says the enrollee does not meet criteria for the HFCWOD.  
 The Plan follows Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically 
necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
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 HFCWODF. Our reviewer says that 
the HFCWOD is not medically necessary. Our physician reviewer found the enrollee does not meet LCD 
criteria for a high frequency chest wall oscillation device. The documentation does not support the benefit or 
improvement with any chest physiotherapy; hence, it is unclear if worked or 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 a HFCWODF have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve a Freestyle Libre 2. You say that the Freestyle Libre 2 is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the information provided was not 
sufficient to support approval for medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. Without medical records, 
we cannot determine whether or not the Freestyle Libre 2 is medically necessary. Therefore, we decided that 
the Plan has to pre-approve a Freestyle Libre 2.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manipulative treatment provided on October 14, 2022. 
 
You asked the Plan to pay for manipulative treatment. You say that you are appealing the claim payment 
denial. 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 manipulative treatment 
provided on October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on January 24, 2023. 
 
You asked the Plan to pay for the electrocardiogram. 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 electrocardiogram 
provided on January 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has metastatic disease with 
tumor mutation burden low and microsatellite instability stable. The review has determined that the requested 
use of Keytruda is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 10, 2022, through 
July 12, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee with history of a stroke presented with vertigo. The enrollee had confusion and was not 
complying with nursing instructions. He was also found to have bacteriuria and was treated with antibiotics. 
Additionally, the enrollee had tachycardia. An inpatient stay anticipated to be greater than two midnights for 
this clinical scenario for this enrollee with multiple acute medical issues was medically 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from July 10, 2022, through July 12, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 22, 2023. 
 
You asked the Plan to pay for lab services. You say that the referring provider is in-network. 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 lab services provided on 
May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nebulizer, with compressor provided from December 25, 
2022, to January 24, 2023. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says code E0570-RR-KX (31 units) remains not supported. 
 
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, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code 
E0570 is "Nebulizer, with compressor." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records do not fully support HCPCS code E0570 as the order does not include the length of need for the nebulizer with start/stop 
dates. 
 
We looked at this coder'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 nebulizer, with compressor provided from December 25, 2022, to January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 28, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you think that you were billed 
incorrectly. 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 $15 
copayment for each specialist visit for Medicare-covered services. 
 
You have been asked to pay a $15 copayment for an office visit. This item/service falls within the each 
specialist visit for Medicare-covered 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 an office visit provided on April 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency wheelchair van transportation service 
(A0130) provided on April 18, 2023. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that the hospital recommended that 
this was the only safe method for transport. The Plan denied your request. The Plan says the non-emergency 
transportation benefit is not covered if the services are not registered with the Plan's designated provider in 
advance. 
 
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 routine wheelchair/stretcher transportation when services are provided by the Plans 
designated provider. 
 
We looked at your request, the records in the case file, and the rules. This transportation was not provided by 
the Plans designated provider. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for the non-
emergency wheelchair van transportation service (A0130) provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network wound care supplies provided 
on December 6, 2022. 
 
You asked the Plan to waive the coinsurance for in-network wound care supplies. You say that you feel you are 
being overcharged for these items. Your wound isn't big enough to warrant this type of cost. 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 (DME) and related services.  
 
The allowed amount of this item is $855.42, resulting in a coinsurance amount of $171.08 ($855.42 x 20% = 
$171.08). You have been asked to pay $171.08 coinsurance for in-network wound care supplies. This item/service falls 
within the durable medical equipment (DME) and related 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 coinsurance for in-network wound care supplies provided on December 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot provided on March 27, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the walking boot. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the item 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 the walking boot provided on March 27, 2023, by 
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on April 24, 
2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you thought that if you were 
hospitalized thee ambulance copayment would be waived. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance ride. This item/service falls within the 
ambulance 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 an ambulance ride 
provided on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 TissueNext testing (81479) provided to the enrollee on October 5, 2021.
You asked the Plan to pay for the Guardant360 TissueNext testing. You say that this test was medically necessary and was reported correctly. The Plan denied your request. The Plan says that they have correctly denied the claim for payment as the Z-Code Z00D0 is not covered for the MoIDX program. Maximus overturned the Plan's denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code Z00D0 coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that confirms this.
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 code. In this case the reported DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for the Guardant360 TissueNext testing (81479) provided to the enrollee on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network sub-acute care level 
admission provided on January 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network sub-acute care level admission. You say that 
these bills are too high to pay with a fixed income. Please dismiss one of the bills to make this more feasible. 
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 $300 
copayment for inpatient hospital care. 
 
You have been asked to pay a $300 copayment for an in-network sub-acute care level admission. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an in-network sub-acute care level admission provided on January 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 11, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that you shouldnt have to 
pay because the doctor didnt do anything. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for an office 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 an office visit provided on May 11, 2022.