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

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 19, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and stated this claim was denied because
the medical records do not include lab results for 15 t0 21 drug classes to support the code billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the records provided do not support the services billed. Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
lab services provided to the enrollee on September 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye repair procedure provided on November 02, 2022. 
 
You asked the Plan to pay for an eye repair procedure. You say that this was medically necessary and 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 an eye repair procedure 
provided on November 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tracheostomy provided on September 28, 2022. 
 
You asked the Plan to pay for tracheostomy. 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 tracheostomy provided 
on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 7, 2021 and billed under code 87481.
You asked the Plan to pay this code. You say that this service should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating they were ordered by a Plan provider. The Plan requested a reopen and stated the issue was not who ordered the service but that the provider billed the wrong code.
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 code. In this case, based on the medical records provided, code 87481 was not the appropriately billed code for the enrollee's diagnosis. Medicare rules for coverage of this code have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on December 7, 2021 and billed under claim with code 87481.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
January 10, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were never told 
that you would have an ambulance charge. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 
ambulance transportation provided on January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 02, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that you say that wound care supplies are a 
separately billable expense that does not requeire authorization or referral. 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 supplies 
provided on February 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intra-oral x-rays (D0210) provided on August 30, 2022.
You asked the Plan to pay for the intra-oral x-rays. You say that this should be covered, and you were not made
aware of the charges. 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 March 9, 2020.
Therefore, we decided that the Plan does not have to pay for the intra-oral x-rays (D0210) provided on August
30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker (E0143) provided to the enrollee on August 29,
2022.
You asked the Plan to pay for the walker. You say that you would like this to be paid. The Plan denied your
request. The Plan says that this patient has previously received the same or a similar item from a different
provider on the same date.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were
reimbursed by the Plan on September 22, 2022. The file confirms a different provider submitted an identical
claim for the same enrollee and the same date of service, that has already been paid by the Plan. Comparison of
the two claims shows these are exact duplicates. There is no evidence presented to support that the billed
items/services were provided twice on the same date. Based on this information, we decided that the Medicare
rules for the walker have not been met. Therefore, we decided that the Plan does not have to pay for the walker
(E0143) provided to the enrollee on August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 29, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
December 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on February 09, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were 
unaware of the copayment for the service rendered. 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 test. 
 
You have been asked to pay a $195 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 
magnetic resonance image (MRI) provided on February 09, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
November 30, 2022. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you fell during your 
appointment and were told to go to the emergency room. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room services. 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 the emergency room 
services provided on November 30, 2022. 
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and problem
focused re-evaluation (D0170).
You asked the Plan to pre-approve a maxillary partial denture and problem focused re-evaluation. You say that
that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the requested
problem focused re-evaluation is not a covered benefit. The Plan also says that you have exceeded your benefit
limit for dentures.
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
maxillary partial denture was exhausted on date of service June 11, 2018.
The requested problem focused re-evaluation is not among those covered under this benefit. Therefore, we
decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and problem focused reevaluation
(D0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network electrocardiogram (EKG) 
provided on February 06, 2023. 
 
You asked the Plan to waive the copayment for an in-network electrocardiogram (EKG). You say that you 
should not have seperate copayments for different services on the same day. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for an in-network electrocardiogram (EKG). 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 in-network electrocardiogram (EKG) provided on February 06, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography procedures provided on September 15, 
2022. 
 
You asked the Plan to pay for echocardiography procedures. You say that this was medically necessary and 
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 echocardiography 
procedures provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve forty (40) additional routine acupuncture treatments.
You asked the Plan to pre-approve forty (40) additional routine acupuncture treatments. You say that you are
requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that you have
exhausted the allowable benefit for these services.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the Plan has provided documentation confirming you
have used 20 acupuncture visits this year and that your benefit is exhausted. Therefore, we decided that the
Plan does not have to pre-approve forty (40) additional routine acupuncture treatments.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) for date of service December 9, 2022. 
 
You asked the Plan to pay for the ultrasound, abdominal aorta, real time with image documentation, screening 
study for abdominal aortic aneurysm (AAA) . You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the enrollee did not meet criteria for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that screening studies for AAA are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee was not between the age of 
65 to 75 who has smoked at least 100 cigarettes in his lifetime. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound, abdominal aorta, real time with image documentation, screening 
study for abdominal aortic aneurysm (AAA) have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound, abdominal aorta, real time with image documentation, screening study for 
abdominal aortic aneurysm (AAA) for date of service December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cardiac event recorder provided on 
January 06, 2023. 
 
You asked the Plan to waive the coinsurance for the cardiac event recorder. You say that you were unaware of 
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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the cardiac event recorder. This item/service falls within the 
durable medical equipment and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $608.64 ($3,043.2 allowed amount x 
20% = $608.64). Therefore, we decided that the Plan does not have to waive the coinsurance for the cardiac 
event recorder provided on January 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
Please reconsider payment. 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 office visit provided 
on February 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on August 23, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. 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 skilled nursing facility 
care provided on August 23, 2022.