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

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided on 
June 09, 2023. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that this was a short 
phone call, and you have paid a lesser copayment for this service in the past. 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 in-network specialist physician/practitioner services. 
 
You have been asked to pay a $30 copayment for the specialist telehealth visit. This item/service falls within 
the in-network specialist physician/practitioner 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 the specialist telehealth visit provided on June 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient diagnostic tests provided on 
January 23, 2023. 
 
You asked the Plan to waive the coinsurance for an outpatient diagnostic tests. You say that you disagree with 
the coinsurance. 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 outpatient diagnostic tests/diagnostic tests andprocedures. 
 
You have been asked to pay 20% coinsurance for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/diagnostic tests andprocedures 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 allowed amount for the diagnostic test is 
$108.17 you are being asked to pay $18.06 ($108.17 x 20% = $21.63). However, since the allowed amount is 
less than the standard coinsurance, you only owe $18.06. Therefore, we decided that the Plan does not have to 
waive the coinsurance for an outpatient diagnostic tests provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99340) provided on November 30, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this service was not provided by a primary 
care provider or a specialty provider. You also say that palliative care visits are provided in the enrollee's 
residence. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 home visit (99340) provided on November 30, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse for the office visits and the laboratory services provided on April 28, 
2022, to May 22, 2023.  
 
You asked the Plan to reimburse for the office visits and the lab services. You say that the enrollee should be 
reimbursed for former payments. The Plan denied your request. The Plan says that 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). The Plan contract does not say in clear and accurate terms how 
much enrollees should expect to pay for the Part B deductible for physician/practitioner services, including 
doctor's office visits.  
 
We looked at the contract between the enrollee and the Plan. We did not see where the contract says enrollees 
must pay a $226 deductible for physician/practitioner services, including doctor's office visits. The Plan 
contract does not clearly say how much enrollees must pay for the Part B deductible. This means that the Plan 
did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan 
has to reimburse for the office visits and the laboratory services provided on April 28, 2022, to May 22, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for transportation services provided out of the country.
You asked the Plan to pay additional reimbursement for these services. The Plan denied your request. The Plan says the maximum $25,000 benefit was paid for out of the country services. Maximus overturned the Plans denial for lack information in the case file to confirm the total benefit was paid. The Plan requested a reopen and provided the necessary information to support the full benefit had been paid.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says the maximum out of the country benefit is $25, 000.
The Plan provided documentation to show the full benefit had been paid. Therefore, we decided that the Plan does not have to pay additional reimbursement for transportation services provided out of the country.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 86695, 86696 and 87389 
provided May 4, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration for the 
denied laboratory charges which were medically necessary for diagnosis and treatment. The Plan denied your 
request. The Plan says medical necessity cannot be established as no clinical information was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Additional records were requested to determine how the enrollee came to the servicing provider, whether the 
billed services were actually performed and that the services were medically necessary. The record show that 
the Plan made multiple attempts to obtain the additional information from the provider without success. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 86695, 86696 and 
87389 provided May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 24, 2021 (81455).
You asked the Plan to pay for these services . You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that this claim denied due to a mismatch between the code 81455 and the billed Z-code ZB9GO, indicating code 81455 cannot be reported with this Z-code.
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 DEX Registry shows that the proper code for the Z code reported is 81479.
The Content and Rules Studio also shows 81479 is the proper code for ZB9GO. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 24, 2021 (81455).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and refraction service provided on June 5, 
2023.  
You asked the Plan to pay for the vision services. You say that you went to get your driver's license renewed 
and were advised you needed a new eye exam. You also say that your eye doctor would not sign the driver's 
license paper without doing an exam. The Plan denied your request. The Plan says the benefit for this service 
has been exhausted. 
 
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 one routine eye exam per calendar year. 
 
We looked at the file and the Plan's rules. The Evidence of Coverage clearly says that one routine eye exam per 
calendar year is covered. Based on this information, we decided that the Plan's rules for coverage of the vision 
services have not been met. Specifically, the file shows that the Plan paid for a routine eye exam previously. 
Therefore, we decided that the Plan does not have to pay for the office visit and refraction service provided on 
June 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an acute Inpatient 
Rehabilitation level of care to address their complex medical condition complicated by comorbidities which 
resulted in their functional impairments and increased risk for medical instability. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate . You say that the enrollee has spinal degeneration 
and has tried physical therapy which caused her pain to increase. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
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 pre-approve bone marrow aspirate . Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate  have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on April 10, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $300 
copayment for outpatient surgery/outpatient hospital. 
 
You have been asked to pay a $300 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient hospital 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 outpatient surgery provided on April 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder x-ray provided on March 20, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the shoulder x-ray. You say that services were provided in good faith. The Plan 
denied your request. The Plan says the services were 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 shoulder x-ray provided on March 20, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 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 January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health treatment provided from  
May 18, 2022, through June 29, 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 these services are not payable as the 
behavioral health facility is not Medicare certified.  
 
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 behavioral health facility at issue is not enrolled in 
the Medicare program. Therefore, we decided that the Plan does not have to pay for the inpatient behavioral 
health treatment provided from May 18, 2022, through June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on October 1, 2022.
You asked the Plan to pay for the electrodes. You say that the supplies were billed using the correct code. The Plan denied your request. The Plan says supplies for the unit are included in the rental allowance. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The provider is billing the units in excess of the Medicare allowed amount. Therefore, this claim was denied correctly.
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 provider is billing for supplies separately for rented equipment, which is not allowed. The provider is also billing in excess of the normal units allowed by the billing guidelines. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on October 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), x-ray exam of the cervical spine 
(72050), x-ray exam of the thoracic spine (72070), x-ray exam of the lumbar spine (72100), and the x-ray exam 
of the pelvis (72170) provided on October 11, 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 you have exhausted the allowable benefit for 
the services provided in this case.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan contract provides supplemental coverage 
for one routine office visit and one set of routine x-rays per year.  
 
The records show that you have exhausted the allowable benefit for the services provided in this case as of  
date of service July 1, 2022. Specifically, the Plans contract states that one routine chiropractic office visit and 
one set of routine x-rays are covered per year. The record shows that you previously received a chiropractic 
office visit and x-rays provided on July 1, 2022 that were paid for by the Plan.   
 
 
 
Therefore, you have exhausted the allowable benefit for the services provided in this case. Therefore, we 
decided that the Plan does not have to pay for the office visit (99213), x-ray exam of the cervical spine (72050), 
x-ray exam of the thoracic spine (72070), x-ray exam of the lumbar spine (72100), and the x-ray exam of the 
pelvis (72170) provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination and evaluation (92012) 
provided on April 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the vision service. You say that you needed a second opinion for a second 
surgery regarding a detached retina. You say that this was your previous provider for 15 years. You also say 
that the doctor that did your previous surgery you had only known for three months. The Plan denied your 
request. The Plan says there is no referral from your primary care physician for this service. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the 
Plan does not have to pay for the medical eye examination and evaluation (92012) provided on April 20, 2023, 
by an out-of-network (OON) provider.