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

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network laboratory visit 
provided on July 28, 2023, to August 10, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network laboratory visit. You say that you were told 
that this would be covered because the lab was in-network. 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 47% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 47% coinsurance for an out-of-network laboratory visit. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $58.76 ($125.02 x 
47% = $58.76). Therefore, we decided that the Plan does not have to waive the coinsurance for an out-of-
network laboratory visit provided on July 28, 2023, to August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits.  

You asked the Plan to pre-approve 3 home health skilled nursing visits. You say that you would like to request 
reconsideration of the denied home health services and that the services requested are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee is noted to be medically stable. Their oxygen saturation is noted to be 96% on room air. They do not 
require wound care, catheterization, G-tube feeding, or administration of IV or complex medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the pneumatic compression 
device should be paid as billed because it was coded correctly and was medically necessary. The Plan denied 
your request. The Plan says the pneumatic compression device is denied because it was not billed correctly. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the acute inpatient hospital services 
provided from April 23, 2023, to April 27, 2023. 
 
You asked the Plan to waive the cost share for the inpatient hospital care. You say that this is a financial 
hardship for you. 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 $240 
copayment for each inpatient hospital stay. 
 
You have been asked to pay a $240 copayment for the inpatient hospital care. This 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 cost share for the acute 
inpatient hospital services provided from April 23, 2023, to April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker boot provided on May 12, 2023. 
 
You asked the Plan to pay for the walker boot. You say that you are asking for the submitted documents to be 
reviewed. 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 walker boot 
provided on May 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service June 9, 2023. 
 You asked the Plan to pay for procedure code 99291. You say that this service was necessary and was coded 
correctly. The Plan denied your request. The Plan says payment for code 99291 is bundled into payment for 
codes 36556 and 36620. 
 
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, we have confirmed that code 99291 
is a column II code to column I codes 36556 and 36620. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of service 
June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a K3 foot and microprocessor knee for the
enrollee.

You asked the Plan to provide coverage for a K3 foot and microprocessor knee. The Plan denied your request.
The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial.

The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that
enrollee's amputation was over 5 years ago. The enrollee uses a wheelchair for mobility. The enrollee has never
ambulated with a prosthesis of any K-level, has not failed use of K2 or K3 mechanical knee. The medical
records do not show why a microprocessor knee is medically necessary in this case.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. The rules also state that a level three ambulator has the ability or potential for
ambulation with variable cadence. Typical of the community ambulator who can traverse most environmental
barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond
simple locomotion. Coverage for a K3 ability prosthetic and/or equipment is extended only if there is sufficient
clinical documentation of functional need for the technologic or design feature of a given type of knee.

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 a K3 foot and microprocessor knee
have been met. Therefore, we decided that the Plan does not have to provide coverage for a K3 foot and
microprocessor knee for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services and the chemotherapy services 
provided on June 05, 2023. 
 
You asked the Plan to pay for the laboratory services and the chemotherapy services. 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 laboratory services 
and the chemotherapy services provided on June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 for date of service August 14, 2023. 
 
You asked the Plan to pay for procedure code 96401. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 code 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 
 
We find that CPT code 96401 is not supported in the medical record. Specifically, the documentation shows 
that Prolia (denosumab) was administered. This code does not support the administration of Prolia. Based on 
this information, we decided that Medicare rules for coverage of procedure code 96401 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 96401 for date of service August 
14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller (E2377) with harness
(E2313) and electronic connection (E2311) for a power wheelchair for the enrollee.

You asked the Plan to provide coverage for the requested upgraded electronics. The Plan denied your request.
The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that an E2311
Electronic Connection, E2377 Expandable Controller and E2313 Expandable Controller Harness
are requested to control power tilt, recline, and power elevating leg rests through the joystick. The notes
state that these are needed when 3 or more actuators are being used. The electronic connection (E2311),
expandable controller (E2377) and harness (E2313) cannot be covered.

Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there
is not a medical need to control these power options through the joystick. As noted above, the enrollee is not
expected to operate the wheelchair independently, since an E2331, Attendant Control has been requested and
approved. The enrollee's caregivers have upper limb strength and function which are adequate to control the
power options using their own switches which are included in the allowance of these power options.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. The medical records submitted do not support that the requested expandable
controller, harness, and electronic connection are medically reasonable and necessary for the enrollee in this
case. Therefore, we decided that the Plan does not have to provide coverage for an expandable controller
(E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anticoagulant management services provided on August 
29, 2023. 
 
You asked the Plan to pay for the anticoagulant management services. 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 anticoagulant 
management services provided on August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G7 Receiver/Sensor. 
 
You asked the Plan to pre-approve Dexcom G7 Receiver/Sensor. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Dexcom G7 Receiver/Sensor. Therefore, we decided that the Plan does not have to pre-approve Dexcom 
G7 Receiver/Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 5, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 5, 2023, billed with 
code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 12, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary, please review 
documents and review. 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 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an electronic connection (E2311), harness
(E2313), and expandable controller (E2377) for the enrollee.

You asked the Plan to provide coverage for an electronic connection, harness, and expandable controller. The
Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan
noted that toggle switches come included with the approved power options and power feature.

The medical records show the enrollee has enough arm strength to push a switch, which is like pushing a
button which makes the upgraded unnecessary.

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. The available clinical documentation in the case file
does not support that the requested expandable controller, harness, and electronic connection were medically
reasonable and necessary for the enrollee in this case. The notes do not show the medical necessity of
controlling the power options through a joystick. Therefore, we decided that the Plan does not have to provide
coverage for an electronic connection (E2311), harness (E2313), and expandable controller (E2377) for the
enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 4, 2023, to 
August 8, 2023. 
 You asked the Plan to pay for home health services. You say that you were not informed of a change in the 
rules for billing the services at issue. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 6, 2023. The NOA was not received by the Plan until October 6, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 4, 2023, to August 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on July 06, 2023. 
 
You asked the Plan to pay for the x-rays. You say that you are requesting reconsideration for the services 
provided. 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 x-rays provided on 
July 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on May 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. If more than one evaluation 
and management (face-to-face) service is provided on the same day to the same patient by the same physician 
or more than one physician in the same specialty in the same group, only one evaluation and management 
service may be reported unless the evaluation and management services are for unrelated problems. 
 We looked at the file and Medicare rules. The records show that an evaluation and management (E&M) service 
was provided by physician of the same specialty and group practice on the same date of service. This service 
was processed and paid by the Plan. As such, a second E&M service is not payable. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for the services (99285) provided on May 15, 2023.