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

 
We decided that the Plan does not have to waive the coinsurance for Part B injection provided on May 15, 
2023. 
 
You asked the Plan to waive the coinsurance for Part B injection. You say that you say that the price of the shot 
keeps going up every time you go to the doctor and you want to know why. 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 Part B 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 you owe is $276.24 ($1,381.20 allowed amount x 20% = $276.24). Therefore, 
we decided that the Plan does not have to waive the coinsurance for Part B injection provided on May 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on June 23, 2023. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration stating you are an 
extension to the doctor in which has an approved authorization on file. 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 injections provided on 
June 23, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 10, 2022, 
through October 20, 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 was admitted on October 10, 2022 with beta blocker overdose, sepsis, and respiratory 
failure. He was evaluated and found to have multivessel coronary artery disease (CAD). During the evaluation 
for a potential coronary artery bypass grafting (CABG) procedure, he was noted to have greater than a 90% 
occlusion of the left internal carotid artery and underwent a left carotid endarterectomy on October 18, 2022. 
He tolerated the procedure and was discharged when considered medically stable on October 20, 2022. The 
review has determined that the record showed that at the time of the inpatient admission it was reasonable for 
the admitting physician to expect that the enrollees necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights with supporting documentation of the 
enrollees history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 October 10, 2022, through October 20, 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 June 21, 2023. 
 
You asked the Plan to pay for lab services. 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. 
 
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 
June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), progressive lenses (V2781), prisms 
(V2715), and tinting (V2745) provided on July l6, 2023. 
 
You asked the Plan to pay for frames (V2020), progressive lenses (V2781), prisms (V2715), and tinting 
(V2745). You say that you were having an eye focus problem that could not be corrected. You also say you 
were referred to a provider who specializes in eyesight focusing. You also say the problem was found, and a 
new prescription was given which finally corrected your eyesight. The Plan denied your request. The Plan says 
after deducting the $200 allowance per your EOC, you were given a 20% discount ($264 submitted charge - 
$200 allowance = $64) ($64 - 20% = $51.20). The Plan also says that the remaining $51.20 is member 
responsibility. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $200 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses. The Plan rules also say you are responsible for any amount over the 
$200 retail price. The record shows this benefit was exhausted with this purchase. Based on this information, 
we decided that the Plan's rules for coverage of frames (V2020), progressive lenses (V2781), prisms (V2715), 
and tinting (V2745) have not been met. Therefore, we decided that the Plan does not have to pay for frames 
(V2020), progressive lenses (V2781), prisms (V2715), and tinting (V2745) provided on July l6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on July 26, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 code J3490 is unclassified drugs. We find that CPT code J3490 
is not supported. Code J3490 was billed to identify Bupivacaine, which is a local anesthetic. If performed to 
facilitate the infusion or injection or hydration, the use of local anesthesia is included and not separately billable. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 provided on July 
26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
February 07, 2023, to February 12, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $285 
copayment for inpatient hospital care. 
 
You have been asked to pay a $285 copayment for the inpatient hospital stay. 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 have been asked to pay a total of $1,425 for the inpatient hospital stay ($285 
copayment x 5 days = $1,425). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on February 
07, 2023, to February 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for code K0553 billed to the enrollee for date of service November
28, 2022.

You asked the Plan to pay this clam. The Plan denied your request. The Plan says the claim was billed with
date errors. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the provider
billed with Date of Service (DOS) November 28, 2022, in error. The provider first submitted K0554 for the
CGM receiver and K0553 for the supplies on November 29, 2022. While this claim was still in progress, on December 14,  the provider submitted a claim as a cancellation bill with the 8 frequency code, referencing the
original claim number, which basically means that they are asking us to cancel.
Claim history then shows that on December 29, 2022 the provider rebilled both K0554 and K0553 as claim
 but for DOS November 27, 2022 this time instead of November 28, 2022. At that point it
appears that the provider realized that they billed for the wrong DOS which explains why they cancelled the
original claim and resubmitted under the corrected DOS. This means the Plan correctly denied K0553 billed for
date of service November 28, 2022, for payment.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly.

In this case, the claim in question could not be paid as billed due to an error with the date of service reported.
Medicare rules for coverage of this clam have not been met. Therefore, we decided that the Plan does not have
to pay for code K0553 billed to the enrollee for date of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic laryngoscopy on April 19, 
2023.  
 
You asked the Plan to waive the deductible for a diagnostic laryngoscopy. You say that you want to appeal the 
amount being charged. 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 $1,000 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 
This cost sharing is a contractual obligation that had not been met at the time a diagnostic laryngoscopy was received on April 19, 2023. Therefore, we decided that the Plan does not have to waive the deductible for a 
diagnostic laryngoscopy on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 25, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 25, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room (ER) visit provided on December 6, 2022, to 
December 9, 2022.  
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says that the services denied correctly as they were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an emergency 
room (ER) visit provided on December 6, 2022, to December 9, 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 laboratory services provided on June 20, 2023. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 15, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Part B injection provided on January 03, 2023. 
 
You asked the Plan to pay for Part B injection. You say that you are requesting reconsideration asking for the 
review of the submitted documents. 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 Part B injection 
provided on January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2391) provided on June 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 June 20, 2023 (D2391 
x2). Therefore, we decided that the Plan does not have to pay for a filling (D2391) provided on June 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided from May 18, 2023, to 
July 13, 2023. 
 
You asked the Plan to pay for the mental health services. You say that you are requesting reconsideration of the 
denied claims. The Plan denied your request. The Plan says the provider is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the mental health services provided from 
May 18, 2023, to July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the shower chair is medically necessary 
because it is dangerous without it. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydrocodone and acetaminophen. 
 
You asked the Plan to pre-approve the drugs. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 
  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 hydrocodone and 
acetaminophen.  
 
Benefits for the drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
November 22, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for caries risk assessment and documentation (D0601) provided 
on August 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for caries risk 
assessment and documentation (D0601) provided on August 21, 2023.