Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 27, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was residing in a nursing 
facility when services were 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 nursing facility care 
provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on July 19, 2022, to May 11, 2023. 
 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $5 copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $5 copayment for 
a specialist office visit. The total allowed amount for the prescription drugs is $7,547.54 ($7,547.54 x 20% = 
$1509.51). However, you met your out-of-pocket maximum, so you are only being asked to pay $920.66. The 
total amount you are being asked to pay is $925.66 ($920.66 + $5 = $920.66). This item/service falls within the 
Medicare Part B prescription drugs and physician/practitioner services/specialist 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 cost share for Medicare Part B prescription drugs and a specialist office visit 
provided on July 19, 2022, to May 11, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric evaluation provided on March 21, 2023. 
 
You asked the Plan to pay for the psychiatric evaluation. 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 psychiatric 
evaluation provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on May 17, 2023. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration for the service 
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 chiropractic care 
provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary should be covered. We 
are in the process of getting in-network. 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 May 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on March 16, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the CT scan provided on 
March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service February 16, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 87798 is 
bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 
billed for date of service February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided to the enrollee on January 13, 2023, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the services provided are not a covered benefit. Maximus overturned the Plan's denial because the correct Evidence of Coverage was not submitted. The Plan requested a reopening and provided to the appropriate 2023 Evidence of Coverage.
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 office visit provided to the enrollee on January 13, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on May 23, 2023, by an 
out-of-network (OON) provider.  
 
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 the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of 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 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 skilled nursing facility care provided on May 23, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 24, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 subsequent nursing 
facility care provided on February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on January 16, 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 
January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided on December 17, 2022, 
and December 19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit". The CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
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 the services. Our reviewer says that the use of codes 99223 
and 99233 is not supported by the records provided. Our reviewer found that the documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity, so CPT 
99223 is not supported. The documentation supports a detailed exam, but not a detailed interval history or 
medical decision making of high complexity, so CPT 99233 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. 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 the services (99223, 99233) provided on December 17, 2022, and December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home ventilator use after three (3) months for the enrollee.
You asked the Plan to pre-approve continued home ventilator use after 3 months. You say that a ventilator is medically necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria have not been met. Maximus partially overturned the Plan's denial. The Plan requested a reopening and confirmed they had already approved three months of ventilator use.
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 continued home ventilator use after 3 months. Our reviewer says that continued home ventilator use after 3 months is not medically reasonable and necessary for the enrollee. This patient has severe COPD and bullous emphysema and has been using a home ventilator since October 1, 2021. The patient's recent compliance with the device is excellent. An arterial blood gas analysis (ABG) from September 29, 2021, showed mild compensated CO2 retention; the patient's circumstances at that time are unclear. It appears this patient's needs could be met with BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued home ventilator use after 3 months. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home ventilator use after 3 months have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home ventilator use after three (3) months for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services, and remote physiologic 
monitoring services provided on March 31, 2023. 
 
You asked the Plan to pay for chronic care management services, and remote physiologic monitoring services. 
You say that these services were medically necessary. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chronic care 
management services, and remote physiologic monitoring services provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care provided on April 13, 2023. 
 
You asked the Plan to pay for the hospital care. You say that you had received authorization from a Plan 
representative. 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 hospital care 
provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that the enrollee continues to get weaker, 
dizzier and has shortness of breath with walking distances with a walker making her at even higher risk of 
falling without this requested equipment. The Plan denied your request. The Plan says Medicare Guidance says 
the upgraded electronics are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve wheelchair accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is able to prepare meals independently and groom and toilet 
independently. Per SSA 1862 (a)1 (a), the enrollee has sufficient strength and function in upper extremities 
to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessory have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and 2 or more power 
seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator provided on May 26, 2023. 
 
You asked the Plan to pay for the home ventilator. You say that You say that the item was medically necessary 
and the provider is in-network with the Plan. 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 ventilator 
provided on May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive hearing test (92557) and the typanometry test (92567) provided on December 7, 2022.
You asked the Plan to pay 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 that you have exhausted the allowable benefit for these services. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that only one hearing test is covered per year. The Plan is correct in this case. The Plan has provided an Explanation of Benefits showing they have previously covered a hearing test on June 21, 2022. Therefore, we decided that the Plan does not have to pay for the comprehensive hearing test (92557) and the typanometry test (92567) provided on December 7, 2022.