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

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
March 3, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that you are appealing the 
denial of the claim. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 a part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only covered when part of 
a routine eye examination. The record shows that this was a medical eye examination, not a routine eye 
examination. Based on this information, we decided that the Plan's rules for coverage of a determination of 
refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a 
determination of refractive state (92015) provided on March 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint 
degenerative disease or stenosis. The cause of the pain is not clear. 
 
  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each primary care provider office visit 
provided on March 27, 2023, to June 02, 2023. 
 
You asked the Plan to waive the copayment for each primary care provider office visit. You say that the 
provider is in-network with the Plan. 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 $40 
copayment for out-of-network primary care physician/practitioner services. 
 
You have been asked to pay a $40 copayment for each primary care provider office visit. This item/service falls 
within the out-of-network primary care 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. The records show the provider is out-
of-network. You have been asked to pay a total of $120 ($40 copayment per visit x 3 visits = $120). Therefore, 
we decided that the Plan does not have to waive the copayment for each primary care provider office visit 
provided on March 27, 2023, to June 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and urinalysis (81002) provided on 
February 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that these services were medically necessary. 
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 office visit (99213) and urinalysis (81002) provided on 
February 27, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 17, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you already 
paid a copayment of $45 and now you are receiving another bill. 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 $325 
copayment for outpatient diagnostic tests.  
You have been asked to pay a $325 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 $125.95, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 22, 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 22, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of 6 
additional PT visits. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy is not generally accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the health plan. The 
records do not demonstrate that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. The requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollees current condition or to prevent or slow further deterioration. The 
enrollee has had ample approved therapy to become proficient in a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional PT visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on February 20, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration for 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 home visit provided 
on February 20, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound study of the arm and leg arteries provided on December 26, 2022, billed with procedure code 93922.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient denial information in the case file. The Plan requested a reopen and noted that the provider billed this claim with diagnosis codes of R20.0, R20.2 and F17.200. These diagnosis codes are not listed in the LCA as acceptable diagnosis codes for the billing of code 93922.
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 codes. In this case, per review of the LCA for date of service December 26, 2022, the diagnosis codes reported are not those that are listed as covered for the billing of code 93922.
Medicare rules for payment of this service have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound study of the arm and leg arteries provided on December 26, 2022, billed with procedure code 93922.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 12, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records. 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 May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing exam provided on June 06, 
2023. 
 
You asked the Plan to waive the copayment for the hearing exam. You say that you already paid at the 
providers office, and do not feel you should have another 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 $15 
copayment for hearing services. 
 
You have been asked to pay a $15 copayment for the hearing exam. This item/service falls within the hearing 
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 hearing exam provided 
on June 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested reopen and noted that Maximus did not apply the full criteria. The Plan notes the medical records show at the time of the appeal the enrollee could only do upper extremity exercises and was unable to sit upright without assistance. The medical records do not show an expectation of the enrollee to be able to participate in the level of therapy provided during an IRF admission.
The Plan is correct in this case. 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. Whether or not there is an opinion that IRF care would be beneficial is not of issue. At the time of the appeal, the enrollee must physically meet certain criteria for Medicare to approve coverage. Based on the medical records and the enrollee's physical condition at the time of the appeal, Medicare coverage criteria were not met as it was not expected that the enrollee would be able to fully participate in an intensive rehabilitative level of therapy. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 11, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you disagree with 
the copayment applied for the ER visit. 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 $95 
copayment for emergency care.  
You have been asked to pay a $95 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cardiac procedure provided on April 
21, 2023. 
 
You asked the Plan to waive the coinsurance for the cardiac procedure. You say that you believe the Plan is not 
paying the correct rate for the procedure code. 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 surgery. 
 
You have been asked to pay 20% coinsurance for the cardiac procedure. This item/service falls within the 
outpatient surgery 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 $2,865.55, which is less than the standard 20% coinsurance. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the cardiac procedure provided 
on April 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 25, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were not told that you would 
be charged for this service. 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 $25 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $25 copayment for an ultrasound. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on May 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone an Take-home 
supply of methadone provided on May 29, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone an Take-home supply of methadone. 
You say that the services 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 medication assisted 
treatment, methadone an Take-home supply of methadone provided on May 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that interspinous distraction devices are experimental. More research is needed. 
 
 
  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interspinous stabilization device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 17, 2022. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that the copayment 
should be waived because the enrollee was admitted. 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 $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on October 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF services. 
 
You asked the Plan to pre-approve continued SNF services. You say that continued SNF services are necessary 
for the enrollee to regain strength to perform basic tasks. The Plan denied your request. The Plan says the 
enrollee has exceeded the Plan benefits limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. You can find this 
information on page 86 of the Plans 2023 EOC. 
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 20, 
2022 to September 27, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued SNF services.