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

 
We decided that the Plan does not have to pay for procedure code 84270 billed for June 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider for code 84270. Without a record showing that this 
provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 84270 billed for June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 05, 2023. 
 
You asked the Plan to pay for the office visit. 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 office visit provided 
on January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced care planning services provided on July 07, 2023. 
 
You asked the Plan to pay for advanced care planning services. 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 advanced care planning 
services provided on July 07, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
18, 2023. 
 
You asked the Plan to pay for the ED services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiological services provided on November 12, 2022, billed
with code 74177-26.

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 provided additional information. The
Plan noted that this claim denied because the provider billed the services without a modifier for payment
consideration. Medicare rules state that services rendered to incarcerated enrollees are not payable. Providers
and suppliers that render services or items to a prisoner or patient in a jurisdiction that meets the conditions of
42 CFR 411.4(b) should indicate this fact with the use of modifier QJ (for A/B MAC (B) or DME MAC
processed claims or for outpatient claims processed by A/B MAC (A).

The Medicare Claims Processing Manual, Chapter 1, Section 10.4, states providers will need to bill modifier
QJ to report services or items provided to a prisoner or patient in state or local custody.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Services provided to incarcerated enrollees cannot be billed for Medicare payment.
Therefore, we decided that the Plan does not have to pay for radiological services provided on November 12,
2022, billed with code 74177-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided July 18, 2023. 
 
You asked the Plan to pay for the office visit. You say that you had called the Plan prior to your appointment 
and was told this is covered 100%. The Plan denied your request. The Plan says this service is not covered 
when billed by a chiropractor. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) provided July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography scans and the diagnostic agent 
provided on September 19, 2022. 
 
You asked the Plan to pay for the computed tomography scans and the diagnostic agent. 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 computed 
tomography scans and the diagnostic agent provided on September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 1, 2023 to June 29, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 1, 
2023 to June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a colonscopy on May 02, 2023. 
 
You asked the Plan to waive the cost share for a colonscopy. You say that you don't feel like you should have 
to pay this amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance of the approved amount, after you meet your deductible. The allowed amount is $568.86 and there 
is a $150 deductible [$568.86 - $150 = $418.86 x 10% coinsurance = $41.89]. For the service it's, $150 + 
$41.86 = $191.89. Therefore, results in the total cost sharing amount of $191.89. 
 
You have been asked to pay a $191.89 cost share for a colonscopy. 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 
cost share for a colonscopy on May 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), foot plate edges, lateral (K0108 x2), bracket assembly, footplate width 
extensions (K0108 x2), liner, polyurethane curved (K0108), and down posts (K0108 x2). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, foot plate edges, 
lateral, bracket assembly, footplate width extensions, liner, polyurethane curved, and down posts. The Plan 
denied your request. The Plan says upgraded electronics (expandable controller, harness and electronic 
connector to 2 power options) are not medically necessary. The cushion cover already included with approved 
cushion. The code used for the footplates does not match the item requested, and cannot be covered. The Plan 
also says the approved wheelchair comes with armrests, and parts for these armrests cannot be requested 
separately. 
 
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 an electronic connection, harness, 
expandable controller, foot plate edges, lateral, bracket assembly, footplate width extensions, liner, 
polyurethane curved, and down posts. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has sufficient 
strength and function in their upper extremities to manage standard power drives. Our reviewer found that the 
foot plates are not coded per existing HCPCS and the liner, polyurethane curved (K0108), and down posts 
(K0108 x2) are included with the wheelchair and may not be billed separately. Our physician reviewer also 
found that the Plan is correct in denying the improper codes and unbundling.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, foot plate edges, 
lateral, bracket assembly, footplate width extensions, liner, polyurethane curved, and down posts have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), 
harness (E2313), expandable controller (E2377), foot plate edges, lateral (K0108 x2), bracket assembly, 
footplate width extensions (K0108 x2), liner, polyurethane curved (K0108), and down posts (K0108 x2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on May 
19, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that the Plan should pay more. 
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 $196 
copayment for Skilled Nursing Facility (SNF) care. 
 
You have been asked to pay a $196 copayment for skilled nursing facility. This item/service falls within the Skilled Nursing Facility (SNF) care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. You have been asked to pay a total of $1,372 for the skilled nursing facility care 
($196 copayment x 7 days = $1,372). Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility provided on May 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 11, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were unaware of the cost share 
for this service. 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 $85 
copayment for outpatient hospital services. 
 
You have been asked to pay a $85 copayment for an ultrasound. This item/service falls within the outpatient 
hospital 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 ultrasound 
provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for an out-of-network eye 
visit and testing provided on February 28, 2023, and March 1, 2023. 
 
You asked the Plan to waive the copayment and coinsurance for an out-of-network eye visit and testing. You 
say that you should not have these large copays. The office told you they were in-network. 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 $60 
copayment, and a 50% coinsurance for vision care.  
 
You have been asked to pay a $126.10 total ($29.78+ $96.32 = $126.10).  You have been asked to pay $126.10 for an out-of-network eye visit and testing. This item/service falls within 
the vision 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 and coinsurance for an out-of-
network eye visit and testing provided on February 28, 2023, and March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 29, 2023, to July 24, 
2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed services are bundled into the inpatient 
admission. 
 
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 the practitioner services provided have 
been met. Specifically, the explanation of benefits provided does not contain the actual denied procedure 
code(s), only revenue code. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on June 29, 2023, to July 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy treatment provided from 
June 12, 2023, to June 19, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatment. You say that you feel the 
coinsurance is too high and you are unable to afford 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 $1,938.34 for chemotherapy treatment. This total includes $986.53 coinsurance, 
which is 20% of the allowed amount for chemotherapy treatment provided on June 12, 2023 ($4,932.65 
allowed x 20% = $986.53) and $951.81 coinsurance, which is less than 20% of the allowed amount for 
chemotherapy treatment provided on June 19, 2023. The coinsurance for services performed on June 19, 2023, 
is less than the standard amount because your maximum out-of-pocket was met during the processing of this 
claim. 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for chemotherapy treatment provided from June 12, 2023, to June 19, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx urinary tract infection (UTI)-ABR molecular 
test panel provided April 21, 2023, billed with codes 87481-90 XU, 87653-90 XU, 87798-90 XU x12, 87801-
90 x3. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. 
 
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 looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx urinary tract 
infection (UTI)-ABR molecular test panel provided April 21, 2023, billed with codes 87481-90 XU, 87653-90 
XU, 87798-90 XU x12, 87801-90 x3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on May 26, 2023. 
 
You asked the Plan to pay for the subsequent hospital care. 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 subsequent hospital 
care provided on May 26, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies, injection services, and the dialysis 
procedure provided on June 02, 2023, to June 30, 2023. 
 
You asked the Plan to pay for the medical supplies, injection services, and the dialysis procedure. 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 medical supplies, 
injection services, and the dialysis procedure provided on June 02, 2023, to June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cystourethroscopy procedure provided 
on July 27, 2023. 
 
You asked the Plan to reduce the copayment for a cystourethroscopy procedure. You say that the enrollee has 
always been charged a lower 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 $250 
copayment for outpatient surgery in an ambulatory surgery center. 
 
You have been asked to pay a $250 copayment for a cystourethroscopy procedure. This item/service falls 
within the outpatient surgery in an ambulatory surgery center 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 reduce the copayment for a cystourethroscopy procedure provided on July 27, 2023.