Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home or residence visit provided on April 04, 2023. 
 
You asked the Plan to pay for home or residence visit. You say that you are appealing the claim payment 
denial. 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 home or residence visit 
provided on April 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 05, 2023. 
 
You asked the Plan to pay for lab services. You say that the referring physician sent the specimen to be 
evaluated. 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 services provided on 
April 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on March 07, 2023. 
 
You asked the Plan to pay for a drug test. 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 a drug test provided on 
March 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blue frame color accessory (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the blue frame accessory does not serve a primary medical purpose. It is a 
color preference item and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 a blue frame color accessory (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Umano OOK Snow Bed Frame (E1399). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested bed is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's plan does not include a 
benefit for a total electric hospital bed, or the convenience features that go beyond the Medicare benefit. 
Medicare rules also say that features on equipment that are for the convenience of the caregiver are not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve an Umano OOK Snow 
Bed Frame (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a pulp vitality test 
(D0460) provided on May 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had to go to a different dentist because you 
needed a root canal. The Plan denied your request. The Plan says these services have been correctly processed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0140 was exhausted on date of service April 28, 2023. The Plan does not cover 
D0460. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a 
pulp vitality test (D0460) provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 26, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you want to appeal the amount 
being charged. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (99070, 98941, 97012, 98943) 
provided on November 10, 2022, to January 16, 2023, by an OON provider.  
 
You asked the Plan to pay for the chiropractic services (99070, 98941, 97012, 98943). You say that you cannot 
afford to pay for the services you received. The Plan denied your request. The Plan says the services are not 
authorized because the provider is out-of-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 chiropractic services (99070, 98941, 97012, 
98943) provided on November 10, 2022, to January 16, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 provided on April 
11, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and 96521. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 
provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing (0315U) provided to the enrollee on October 25, 2022.
You asked the Plan to pay for the testing. You say that these services were medically necessary. The Plan denied your request. The Plan says that they have correctly denied the claim for payment as Z-Code ZBBLD is not covered for the MoIDX program. Maximus overturned the Plan's denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code ZBBLD coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that confirms this.
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 the reported DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for the testing (0315U) provided to the enrollee on October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast cancer index test provided on May 25, 2023. 
 
You asked the Plan to pay for a breast cancer index test. You say that this test was 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 a breast cancer index 
test provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visits provided on February 2, 2023, to February 
27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for telehealth visits. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the 
enrollee approval in advance before they can use providers not in the plan's network. This is called giving the 
enrollee a "referral." 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 telehealth visits provided on February 2, 2023, to 
February 27, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network nerve test provided on 
August 22, 2022. 
 
You asked the Plan to waive the copayment for an in-network nerve test. You say that you cannot afford this 
copayment and need it removed. 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 $75 
copayment for all other diagnostic procedures and tests. 
 
You have been asked to pay a $75 copayment for an in-network nerve test. This item/service falls within the all 
other diagnostic procedures and 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. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network nerve test provided on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on October 4, 2022.
You asked the Plan to pay for the electrodes. You say that the supplies were billed correctly. The Plan denied your request. The Plan says that the provider did not submit any evidence that they have been contacting the member before shipping additional supplies.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the supplies being dispensed. Based on this information, we decided that Medicare rules for coverage of the electrodes have not been met. Therefore, we decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an injection provided on April 11, 2023. 
 
You asked the Plan to reduce the coinsurance for an injection. You say that you disagree with the cost share 
applied. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the Medicare Part 
B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. The total you owe is $320.43, which is 20% of the allowed amount for a Medicare Part B drug injection ($1,602.16 allowed x 20% = $320.43). Therefore, we decided that the Plan does not have to reduce 
the coinsurance for an injection provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on April 17, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were unaware you that 
would have a 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the urgently needed 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 an urgent 
care visit provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle (81479) provided to the enrollee on October 26, 2022.
You asked the Plan to pay for the testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they have correctly denied the claim for payment as the Z-Code Z00D5 is not covered for the MoIDX program. Maximus overturned the Plan's denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code Z00D5 coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that confirms this.
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 the reported DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle (81479) provided to the enrollee on October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had a positive stress test, but there is no documentation that anti-anginal 
medications have been used.  Guidelines do not support a need for cardiac catheterization at this juncture. As a 
result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on November 27, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that this test should be covered. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the correct unique identifier. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. The Z-code on the claim is not listed as valid for the CPT code billed. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on November 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 25, 2023, and March 27, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not request the services. You also say you have submitted the billing statements for review. 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 Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 25, 2023 to March 27, 2023. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment with no transport provided on March 25, 2023, and March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 23, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 March 23, 2023.