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

We decided that the Plan does not have to waive or reduce the cost share charged for an emergency room ($90)
visit and advanced imaging ($275) provided on October 4, 2022.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the
Plans denial and stated you should only be charged the emergency room copayment. The Plan requested a
reopen and stated that emergency room services as well as images provided by the facility during the
emergency room visit are considered outpatients services. The Plan states the contract is clear that enrollees
have a cost share for each outpatient service provided.
The Plan is correct in this case. 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 $90 copayment for emergency room services and a $275 copayment for
advanced imaging in an outpatient facility. 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 or reduce the cost share charged for an
emergency room ($90) visit and advanced imaging ($275) provided on October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for lab services (81321) provided to the enrollee on August 17, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided so not support the services billed. Maximus overturned the Plans
denial for Plan directed care. The Plan requested a reopen and noted that the provider did not submit records or
documentation to show this test was appropriately ordered or medically necessary.
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 these services have been met. Therefore, we decided that the Plan does not have to pay for
lab services (81321) provided to the enrollee on August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found given the enrollee's prior history of a fall from profound diarrhea, the inpatient 
admission for inpatient preparation for colonoscopy is medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from June 19, 2022, to 
June 20, 2022.  
 You asked the Plan to pay for the inpatient hospitalization. You say that the attending/treating physician 
ordered inpatient admission based on the exercise of professional medical judgement and in the best interest of 
the patient. The Plan denied your request. The Plan says the clinical records do not support a reasonable 
expectation that the patient would require hospital services extending beyond 2 midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for the inpatient hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the patient being stable without a complex presentation, it was not expected 
that they would have required hospital services that would have likely crossed 2 midnights or led to an adverse 
event if not admitted. 
 
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 inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided from June 19, 2022, to June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the vertebral axial decompression, per 
session (S9090), low-level laser treatments (S8948), and the preventive medicine counseling and/or risk factor 
reduction intervention(s) (99204) provided from January 3, 2023, through February 27, 2023.  
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the vertebral axial decompression, per session (S9090), 
low-level laser treatments (S8948), and the preventive medicine counseling and/or risk factor reduction 
intervention(s) (99204) provided from January 3, 2023, through February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient L1 percutaneous vertebral augmentation, 
represented by CPT code 22514. 
 
You asked the Plan to pre-approve outpatient L1 percutaneous vertebral augmentation. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that outpatient L1 percutaneous vertebral augmentation is 
only covered for certain indications. 
 
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 outpatient L1 percutaneous vertebral 
augmentation. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the enrollee was diagnosed with an L1 
compression fracture which began after a mechanical fall in March. There is no trial of fracture bracing. More 
conservative measures needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient L1 percutaneous vertebral augmentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve outpatient L1 percutaneous vertebral 
augmentation, represented by CPT code 22514.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight portable motorized/power wheelchair 
(K0012) purchased on December 31, 2022. 
 
You asked the Plan to pay for the lightweight portable motorized/power wheelchair. You say that the enrollee's 
primary care physician prescribed a motorized wheelchair due to medical necessity. The Plan denied your 
request. The Plan says no evidence was found that the enrollee, the enrollee's power of attorney, nor any of the 
enrollee's family members had called to verify benefits. The Plan also says that no unique circumstances that 
would allow for an exception to cover the purchase of a wheelchair were found.  
 
The Plan must follow Medicare rules. Medicare rules say that the DMECS states that code K0012 is considered 
a capped rental item, and this item may only be rented. 
 
We looked at the file and Medicare rules. Specifically, this item cannot be paid for because it has been 
purchased by the enrollee. The lightweight portable motorized/power wheelchair (K0012) is considered a 
capped rental item, and cannot be purchased. Based on this information, we decided that Medicare rules for 
coverage of the lightweight portable motorized/power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pay for the lightweight portable motorized/power wheelchair (K0012) purchased 
on December 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the MyoPro is supported as an 
appropriate intervention and is reasonably and medically necessary as recognized by medical communities and 
key opinion leaders in rehabilitation. The Plan denied your request. The Plan says medical studies have not 
proven this service/item is helpful for the treatment of the enrollee's health problem. 
 
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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's condition or in widespread use for this patient's condition based on scientific evidence. 
Our reviewer found that there is insufficient evidence in the literature that the MyoPro Orthosis will improve 
the long-term outcomes for this patient. Our physician reviewer also found that there is insufficient evidence in 
the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter lift for your truck. 
 
You asked the Plan to pre-approve a scooter lift for your truck. You say that you need a lift to get your scooter 
in and out of your truck. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a scooter lift for your truck.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical effectiveness of this therapy has not been established. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient evidence in the literature that this device is effective for the enrollee's tremor. 
The requested items are not the standard of care for this enrollee's tremor according to current guidelines.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Cala Trio device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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 (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has COPD with chronic respiratory failure and when admitted improved with BIPAP therapy, in 
additional to medical interventions. The enrollee does not show failure of BIPAP and, in fact, stated that they 
feel better after BIPAP therapy. There is no indication for a home ventilator per the documentation provided. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for procedure code 88305. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 88305 is not appropriate for the services 
at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 88305. Our reviewer says that procedure 
code 88305 does not meet criteria for payment. Our reviewer found that the laboratory report describes 
multiple prostate biopsies, and in this case, when billing Medicare (or as directed by another payor) with the 
G0416 code, it is appropriate to only bill for one unit. The code is all-inclusive, regardless of whether the pathologist did 6 separate biopsy specimens or 20. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88305 billed for date of service May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on December 3, 2022. 
 
You asked the Plan to reimburse for hearing aids. You say that you never received a letter for the denial. You 
also say that you are requesting partial payment for the hearing aids. The Plan denied your request. The Plan 
says there is no coverage for hearing aids when received from a provider other than the Plan hearing. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through an in-network Plan hearing provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on December 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing services (81479) provided on October 11, 2021.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information. The Plan noted while provider did bill unique identifier of Z00D0, review of the Medicare
guidance and Diagnostics Exchange Registry, shows code Z00D0 is not covered for the MoIDX program. As
test is not covered for the Z-code billed, Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, this claim could not be paid as billed due to the billing of an ineligible Z code. Medicare rules for
coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for
genetic testing services (81479) provided on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each cataract surgery provided on May 
16, 2023, to May 30, 2023. 
 
You asked the Plan to reduce the coinsurance for each cataract surgery. You say that you would like these 
services reprocessed at the in-network benefit level. 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 30% 
coinsurance for out-of-network outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay 30% coinsurance for each cataract surgery. This item/service falls within the out-of-network outpatient surgery, including services provided at ambulatory surgical centers 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 amount you owe for 
each surgery is $337.53 ($1,125.11 allowed amount x $30% = $337.53). The total amount you owe is $675.06 
($337.53 coinsurance x 2 surgeries = $675.06). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for each cataract surgery provided on May 16, 2023, to May 30, 2023.