Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid charging unit (V5267) and 
the ear molds purchased on July 10, 2023. 
 
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 aid charging unit and 
the ear molds purchased in this case are not a covered benefit.  
 
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 plan's coverage rules apply in this case.  
 
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 items at issue in this case are not a covered benefit.  
  
Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aid charging unit 
(V5267) and the ear molds purchased on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each intravenous infusion (96365). 
 
You asked the Plan to waive the copayment for each intravenous infusion . You say that the cost share is 
wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment for outpatient hospital services.  
 
The enrollee is responsible for a $1,150.20 cost share. A deductible of $ 79.84 that applied to the May 10th of 
2023 date of service and a $295 copayment amount for each service. However, since the allowed amount is less 
than the copayment amount, the enrollee only owes 230.04 for each date of service, other than on May10th 
which applied a $150.20 copay due the $79.84 that was applied toward the deductible. This item/service falls within the outpatient hospital services benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for each intravenous infusion (96365).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 9, 
2023. 
 
You asked the Plan to pay for the billed code. You say that testing is needed to monitor possible opioid abuse.  
The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 83789 billed for date of service August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on August 3, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for OON services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the OON 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
The records show that a prior authorization was requested but was denied by the Plan. We found no exception 
that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay 
for the wound care services provided on August 3, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service May 7, 2023. 
 
You asked the Plan to pay for the billed service. You say that the service has been improperly down coded. The 
Plan denied your request. The Plan says the billed code is 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
 We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee 
presented with a headache. The enrollee was in no acute distress with no focal neurologic deficits. The medical 
records do not support a high level of medical decision making. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99285 billed for date of service May 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the trifocal spherocylinder (V2303 x2), polycarbonate or equal lenses (V2784 x2), anti-reflective coating (V2750), vision items or services (V2799 x2), and polarization (V2762) provided on March 8, 2023, and March 9, 2023, by a non-Plan approved vision care provider.

You asked the Plan to pay for the eyewear. You say that you have gone to this provider for years, and they were still in-network at the time of your eye exam on March 8, 2023. You also say to claim the provider was not a provider for vision service or eyewear is incorrect, and the Plan should have paid the $200 toward your glasses. The Plan denied your request. The Plan says the treating provider was not contracted to provide vision services or vision eyewear for your benefit plan.

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 these services when they are provided by a Plan-approved vision care provider.

We looked at the file and the Plan's rules. Specifically, Medicare does not cover the purchase of routine eyewear outside of following cataract surgery. The Plan offers eyewear as an additional benefit; however, the eyewear must be ordered through a Plan-approved vision vendor. These services were rendered by a provider who is not in network with the Plan. Eyewear purchased outside of the Plan's approved Vision network is not covered. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the trifocal spherocylinder (V2303 x2), polycarbonate or equal lenses (V2784 x2), anti-reflective coating (V2750), vision items or services (V2799 x2), and polarization (V2762) provided on March 8, 2023, and March 9, 2023, by a non-Plan approved vision care provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) on tooth number 13 provided on 
July 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the claims department assured you the 
claim would be sent back to processing with the correct code. 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 Plan's 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 July 12, 2023. Therefore, 
we decided that the Plan does not have to pay more for the crown (D2740) on tooth number 13 provided on 
July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Inogen One Portable oxygen concentrator and 
battery purchased on August 2, 2023. 
 
You asked the Plan to reimburse you for the oxygen equipment. You say that with a doctor's authorization you 
thought this would be covered and do not understand why reimbursement was not made.  The Plan denied your 
request. The Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to reimburse you for the 
Inogen One Portable oxygen concentrator and battery purchased on August 2, 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), expandable controller (E2377), and power seat elevation system (E2300) for the enrollee.

You asked the Plan to provide coverage for an electronic connection (E2311), harness (E2313),
expandable controller (E2377). You say that at the time of the appeal, the upgraded electronics were medically
necessary. 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 medical records show the enrollee has the required upper extremity strength and range of motion
to operate the standard switches provided with approved base.

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.

We looked at the file and Medicare rules. The Plan is correct in this case. 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).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a pegfilgrastim injection and the 
brentuximab vedotin injections provided on August 04, 2023, to August 18, 2023. 
 
You asked the Plan to reduce the coinsurance for a pegfilgrastim injection and the brentuximab vedotin 
injections. You say that you cannot afford 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a pegfilgrastim injection and the brentuximab vedotin 
injections. 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 reduce the coinsurance for a pegfilgrastim injection and the brentuximab vedotin injections 
provided on August 04, 2023, to August 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on September 4, 2022. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on September 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital services provided on 
July 17, 2023, to July 24, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital services. You say that you should not be 
responsible for everyday you were in the hospital 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 $305 
copayment for inpatient hospital care. 
 
You have been asked to pay a $305 copayment for the inpatient hospital services. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You are responsible for a $2,135 copayment ($305 x 7 days). Therefore, we decided that 
the Plan does not have to reduce the copayment for the inpatient hospital services provided on July 17, 2023, to 
July 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron. You asked the Plan to pre-approve the 
medication. You say that the requested drug is medically necessary. The Plan denied your request. The Plan 
says the medication is not covered as a medical benefit under the Plan. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although an oral anti-emetic such as ondansetron may be covered by Medicare Part B, this 
request does not fall under Medicare Part B coverage because the oral anti-emetic drug is not being initiated 
within 2 hours of the administration of cancer chemotherapy and continued for a period not to exceed 48 hours 
from that time. The oral anti-emetic drug is not being used as a full therapeutic replacement for intravenous 
anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. 
Therefore, we decided that the Plan does not have to pre-approve ondansetron.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an primary care office visit provided on 
August 01, 2023. 
 
You asked the Plan to waive the copayment for an primary care office visit. You say that you should not have 
to pay this 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an primary care 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 primary care office visit provided on August 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 (Factor V Leiden) gene testing. 
 
You asked the Plan to pre-approve F5 gene test. You say that you might get a blood clot. The Plan denied your 
request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that F5 genetic testing is not considered to be 
clinically efficacious so is not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F5 gene test have not been met. Therefore, we decided that the Plan does not have to pre-approve 
F5 (Factor V Leiden) gene testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a DaTscan for the enrollee.

You asked the Plan to provide coverage for a DaTscan. The Plan denied your request. The Plan says medical
necessity has not been established by the records provided. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the requested
DaTscan is not able to distinguish between different types of parkinsonism. It is only useful for distinguishing
between Parkinson's Disease and essential tremor. The Plan states while the records mention the enrollee has
"minimal tremors in both hands,", there is no mention of or description of essential tremor.

Given the neurologist's clinical assessment and findings, the requested examination would not provide
additional useful diagnostic clinical information.

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 literature regarding a DaTscan notes that a diagnosis of
Parkinson's disease (PD) via DaTscan and a neurologist clinical exam are similarly accurate. It is stated that in
most cases, PD can be correctly diagnosed by clinical exam since there are many characteristic features of PD
that can be easily elicited. Therefore, despite the DaTscan being available to help diagnose Parkinson's, a
DaTscan will not add information to what can be gleaned from the clinical exam. The literature goes on to
stated one study demonstrated that the accuracy of diagnosis in early PD was the same whether the diagnosis
was reached using clinical exam or using DaTscan. We looked at the file and Medicare rules and the clinical
definition of a DaTscan. Based on this information, we decided that there is insufficient information in the
record to determine if Medicare rules for coverage of a DaTscan have been met. Therefore, we decided that the
Plan does not have to provide coverage for a DaTscan for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee on December 14,
2022.

You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says the records submitted do not support the services billed. Maximus overturned the
Plans denial for insufficient medical records. The Plan requested a reopen and noted it was explained in the
original case file that the records submitted by the provider were incomplete.

The Plan is correct in this case. 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 this claim have been met. Therefore, we decided that the Plan does not have to
pay for inpatient care provided to the enrollee on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) and the localized 
delivery of antimicrobial agents (D4381) on August 17, 2023. 
 
You asked the Plan to pay more for the periodontal maintenance (D4910) and the localized delivery of 
antimicrobial agents (D4381). You say that periodontal maintenance is allowed four times a year. You say the 
Plan paid for your wife's scaling in 2023 with the same provider. The Plan denied your request. The Plan says 
you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider.   
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the periodontal maintenance (D4910). This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the localized delivery of antimicrobial 
agents (D4381) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay more for the periodontal maintenance (D4910) and the localized delivery of antimicrobial agents 
(D4381) on August 17, 2023.