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

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from June 1, 2023, to June 30, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you want this reprocessed because 
you are receiving bills. 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 $0 
copayment per day, days 1 to 20, and a $60 copayment per day, days 21 to 100 for skilled nursing facility 
(SNF) care. 
 You have been asked to pay a total cost of $474.60 for a SNF stay. This item/service falls within the skilled 
nursing facility (SNF) 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 a skilled 
nursing facility (SNF) stay provided from June 1, 2023, to June 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you are on a 
fixed income and cannot afford to pay the billed amount for the CT scan. 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 $195 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $195 copayment for the computed tomography (CT) scan. 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 the computed tomography (CT) scan provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lymphedema machine to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the lymphedema machine . You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for 
more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-
of-network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the lymphedema machine to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided on July 31, 2023. 
 
You asked the Plan to pay for office visit services. 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 office visit services 
provided on July 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the TOPS system (0202T) and 
associated inpatient admission. 
 
You asked the Plan to pre-approve the implantation of the TOPS system and associated inpatient admission. 
You say that this procedure is medically necessary and is the most appropriate treatment for the enrollee. The 
Plan denied your request. The Plan says more research is needed to show safety and efficacy of the procedure. 
 
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 the implantation of the TOPS system 
and associated inpatient admission. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the TOPS system is 
experimental. More research is needed to show safety and efficacy.  
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 implantation of the TOPS system has not been met. The inpatient admission 
is not covered because the associated procedure that is not covered. Therefore, we decided that the Plan does 
not have to pre-approve the implantation of the TOPS system (0202T) and associated inpatient admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a Vacuum socket system (L5781) for the enrollee.

You asked the Plan to provide coverage for the Vacuum socket system (L5781). You say that this item is
medically necessary. The Plan denied your request. The Plan says a Vacuum socket system (L5781) is not
covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria. The Plan noted that there is limited published literature that
examines the efficacy of the requested socket. The studies do not demonstrate that the use of the Vacuum
socket system provided consistent statistical clinical significance over traditional equipment. Future studies and
research work are required to prove or demonstrate medical necessity.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that investigational
devices are not covered. The Plan has demonstrated that the Vacuum socket system is not currently a covered
option for Medicare enrollees. Therefore, we decided that the Plan does not have to provide coverage for a
Vacuum socket system (L5781) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin biopsy, the office visit and the laboratory service 
provided on May 18, 2023. 
 
You asked the Plan to pay for the skin biopsy, the office visit and the laboratory service. 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 skin biopsy, the 
office visit and the laboratory service provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chiropractic manipulative treatment 
provided by a chiropractor on August 21, 2023. 
 
You asked the Plan to waive the coinsurance for the chiropractic manipulative treatment. You say that you do 
not agree with the denial of payment for the chiropractic service you received. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to chiropractic services.  
 
The item or service you asked the Plan to waive the copayment for falls within the chiropractic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time the chiropractic manipulative treatment was received on August 21, 2023. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the chiropractic manipulative treatment 
provided by a chiropractor on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the recliner chair (A9270) 
 
You asked the Plan to pre-approve the recliner chair. You say that you are requesting an appeal to show that 
you do have arthritis in your pelvic region and hip joints. The Plan denied your request. The Plan says the 
recliner chair does not fit the Medicare definition of DME. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism.  
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. The item at issue in this appeal does not serve a purpose that is 
primarily medical in nature. This item is available to the general public and would be helpful even to those who 
are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the recliner chair 
(A9270)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 17, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 service 
provided on May 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on March 18, 2023. 
 
You asked the Plan to pay for an x-ray. You say that this was medically necessary and should be covered. This 
patient is in a nursing facility and is bed-bound. 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 x-ray provided on 
March 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on August 10, 
2023. 
 
You asked the Plan to pay for the general health panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87532, 87486, 87496, 87498, 87634, 
87581, 87150and 87541) billed for date of service July 25, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says the service at issue is a laboratory panel which 
was not billed with a single panel code as required by Medicare billing guidelines. 
 
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 panel (87532, 87486, 87496, 87498, 87634, 87581, 87150and 
87541) billed for date of service July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on August 14, 2023. 
 
You asked the Plan to pay for wound care services. 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 wound care services 
provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on March 01, 2023, to March 
31, 2023. 
 
You asked the Plan to pay for outpatient services. 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 outpatient services 
provided on March 01, 2023, to March 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on July 29, 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 29, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable gaseous oxygen system and an oxygen concentrator for 
13 months. 
 
You asked the Plan to pre-approve a portable gaseous oxygen system and an oxygen concentrator for 10 
additional months. You say that  The Plan denied your request. The Plan says that a home portable gaseous 
oxygen and oxygen concentrator are considered not medically necessary for 10 additional months.  
 
  The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 a portable gaseous oxygen system and 
an oxygen concentrator for 10 additional months Our reviewer says that a portable gaseous oxygen system and 
an oxygen concentrator for 10 additional months is medically necessary. Our physician reviewer found that the 
enrollee has documented desaturation with ambulation and meets the criteria for ambulatory oxygen therapy. 
Therefore, there is reasonable indication, per documentation for ambulatory supplemental oxygen therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable gaseous oxygen system and an oxygen concentrator for 10 additional 
months have been met.  Therefore, we decided that the Plan has to pre-approve a portable gaseous oxygen 
system and an oxygen concentrator for 10 additional months.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on July 31, 2023. 
 
You asked the Plan to pay for the wound care supplies. 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 wound care supplies 
provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a wellness visit and evaluation visit 
provided on August 23, 2023. 
 
You asked the Plan to waive the copayment for a wellness visit and evaluation visit. You say that this was your 
annual visit, anything discussed should fall under that. 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 a wellness visit and evaluation 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 a wellness visit and evaluation visit provided on August 23, 2023.