Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve provide coverage for a seat lift, expandable controller, Q-logic controller, and assembly labor for a power wheelchair (E2300, E2377, E2313, E2311, K0108, A9900, A9900).
You asked the Plan to provide coverage for several power wheelchair accessories. You say that at the time of the appeal, the requested power wheelchair accessories were medically necessary. The Plan denied your request. The Plan says while the power wheelchair and Medicare allowed accessories were approved, Medicare coverage criteria were not met for the accessories that were denied. Maximus agreed with the Plan.
You requested an ALJ hearing. The ALJ reviewed the documentation and remanded the case back to us because they felt the correct Evidence of Coverage or Plan contract was not submitted. We asked the Plan to resubmit the appropriate Plan contract for the type of health plan you are enrolled in. The Plan resubmitted the Plan contract associated with your coverage. After review of this contract, it was determined our decision is unchanged.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for power wheelchair accessories. 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 these accessories. Our physician reviewer found the medical records show you are physically capable of operating the approved power wheelchair's power features using the standard controls. The expandable controller is not medically necessary. The Q-Logic controller is not separately billable from the expandable controller. In addition, at the time of the appeal, a power seat elevation feature was non-covered under Medicare rules. It should also be noted assembly labor is included in the base payment for the power wheelchair and the provider is not allowed to charge separately for that service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to provide coverage for a seat lift, expandable controller, Q-logic controller, and assembly labor for a power wheelchair (E2300, E2377, E2313, E2311, K0108, A9900, A9900).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 17, 2023, billed with 
codes 87498, 87502, 87634, 87798, U0003 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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. 

The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 17, 2023, billed with codes 87498, 87502, 87634, 87798, U0003 and U0005.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
January 16, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that there were not any 
polyps found or 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 $325 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $325 copayment for the diagnostic colonoscopy. This item/service falls within 
the in-network outpatient surgery 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 records show a diagnostic colonoscopy was provided (code 45378), and the 
outpatient surgery copayment was correctly applied. Therefore, we decided that the Plan does not have to 
waive the copayment for the diagnostic colonoscopy provided on January 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 09, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
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 $245 
copayment for ambulance services. 
 
You have been asked to pay a $245 copayment for ambulance services. 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 ambulance services 
provided on May 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for high compression bandage and sterile water provided on 
April 04, 2023. 
 
You asked the Plan to pay for high compression bandage and sterile water. You say that this service is 
supported in the records. 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 high compression 
bandage and sterile water provided on April 04, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 15, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that this service is supported in the records. 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 psychotherapy provided 
on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the breathing capacity test, and the 
electrocardiogram provided on May 31, 2023, by an OON provider.  
 
You asked the Plan to pay for the office visit, the breathing capacity test, and the electrocardiogram. You say 
that you are appealing the denial with supporting documentation. The Plan denied your request. The Plan says 
these services were not authorized. 
 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 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, the breathing capacity test, and the 
electrocardiogram provided on May 31, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left side L4-5 lateral lumbar interbody fusion 
followed by an L4-5 posterior instrument fusion done through a minimally invasive percutaneous approach.  
 
You asked the Plan to pre-approve the fusion surgery. You say that the surgery is medically necessary.  The 
Plan denied your request. The Plan says the surgery is not medically necessary. The Plan says the enrollee is 
currently a smoker and tobacco product cessation must be done six weeks before the planned surgery, and the 
specific type of allograft to be used was not obtained.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the fusion surgery. Our reviewer says 
that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of smoking cessation which is a contraindication to fusion.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the fusion surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the left side L4-5 lateral lumbar interbody fusion followed by an L4-5 posterior 
instrument fusion done through a minimally invasive percutaneous approach.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to change the copayment for an in-network magnetic resonance 
imaging (MRI) of the pelvis 
 
You asked the Plan to change the copayment for a pelvic MRI. You say that you were told this service would 
only have a $180 copayment, not this large $552.97 charge. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. You are being charged the $552.97 towards your $850 2023 deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is an $850 deductible which applies to outpatient diagnostic tests.  
 
The item or service you asked the Plan to change the copayment for falls within the outpatient diagnostic tests 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an 
$850 deductible which applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that 
had not been met at the time a pelvic MRI was received on May 4, 2023. Therefore, we decided that the Plan 
does not have to change the copayment for an in-network magnetic resonance imaging (MRI) of the pelvis
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home blood pressure monitor.
You asked the Plan to provide coverage for a home blood pressure monitor. . You say that a home blood pressure monitor is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare. Maximus overturned the device as medically necessary. The Plan requested a reopen and stated the issue is not medical necessity but the fact that home blood pressure monitors are not covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. This device is requested for precautionary measures. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to provide coverage for a home blood pressure monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 64702 and 64704 rendered to the enrollee
on April 22, 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 as
medically necessary. The Plan requested a reopen and noted that they agree the services were performed,
however, a fasciectomy (26123) was also performed at the same encounter. Code 26123 has a Correct Coding
Initiative (CCI) conflict with both codes 64704 and 64702. Due to this these codes should not be paid
separately as they are included in the work performed under the code reported for the fasciectomy, 26123.
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, codes 64704
and 64702 were billed separately in error. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for procedure codes 64702 and 64704 rendered to the
enrollee on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 11, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the copayment 
applied for the office visit. 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 
copayment for physician/practitioner services. 
 
You have been asked to pay a $20 copayment for an office visit. This item/service falls within the 
physician/practitioner 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 office visit provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided from June 6, 2022, to 
November 21, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you are enrolled in a program that 
provides the injections free of 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $1,800.05 for Medicare Part B drug injections. This total is less than the standard 
amount for Medicare Part B drug injections because your maximum out-of-pocket was met. 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 injections provided from June 6, 2022, to November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 14, 2023, to May 29, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was nedically 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 office visit provided 
on April 14, 2023, to May 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint 
degenerative disease or stenosis. The cause of the pain is unclear.   
 
  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on July 20, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the physical therapy. You say that you have never needed a referral for these 
services. The Plan denied your request. The Plan says the services were not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 physical therapy provided on July 20, 2023, by 
an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for PT services provided on April 18, 2023. 
 
You asked the Plan to waive the cost share for PT services. You say that the enrollee should only be 
responsible for a $25 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. The 
enrollees contract with the Plan says that there is a $500 deductible which applies to outpatient rehabilitation 
services and a $25 copayment for physical therapy services, after the deductible has been met.  
 
The enrollee has been asked to pay $68.74 for PT services. This total includes a $59.45 deductible, and a $9.29 
copayment, which is less than the standard copayment for PT services. The item or service you asked the Plan 
to waive the cost share for falls within the outpatient rehabilitation services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time 
physical therapy services was received on April 18, 2023. However, the enrollees deductible was met with the 
processing of this claim. Therefore, we decided that the Plan does not have to waive the cost share for PT 
services provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 14, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you are requesting reconsideration for 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 anesthesia services 
provided on June 14, 2022.