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

 
We decided that the Plan does not have to waive the copayment for the remote monitoring services provided on 
February 18, 2023, to May 08, 2023. 
 
You asked the Plan to waive the copayment for the remote monitoring services. You say that you disagree with 
the copayments. 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 $150 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $150 copayment for the remote monitoring services. This item/service falls 
within the in-network 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. However, you only owe $17.73 for each service. The total amount 
you owe is $53.19 ($17.73 copayment x 3 visits = $53.19). Therefore, we decided that the Plan does not have 
to waive the copayment for the remote monitoring services provided on February 18, 2023, to May 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram and the office visit provided on 
February 15, 2023. 
 
You asked the Plan to pay for an electrocardiogram and 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 an electrocardiogram 
and the office visit provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 01, 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 August 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 03, 2023. 
 
You asked the Plan to pay for lab services. You say that these services do not require authorization. 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 
August 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a lift chair purchased on May 18, 2023, from an 
out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for a lift chair. You say that you need the lift chair to put your foot above 
your heart. You paid out of pocket, and you want to be reimbursed. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 reimburse you 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for a lift chair purchased on 
May 18, 2023, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 18, 2023, billed with 
procedure codes 97530 and 97535. 
 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 diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F01.B0, described 
as vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and 
anxiety. This code is not an appropriate primary diagnosis as the code has a code first note indicating to code 
the underlying condition first. Based on this information, we decided that Medicare rules for payment of this 
claim have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on July 18, 2023, billed with procedure codes 97530 and 97535.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84075, 84460, 82247, 82947, 84550) 
related to end-stage renal disease (ESRD) provided on June 2, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. 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 (84075, 84460, 82247, 
82947, 84550) related to end-stage renal disease (ESRD) provided on June 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and multiaxial ankle and
hydraulic active dorsiflexion (L5968) for the enrollee.

You asked the Plan to pre-approve a flex-walk system and multiaxial ankle and hydraulic active dorsiflexion.
You say that these items are medically necessary. The Plan denied your request. The Plan says that the request
for K3 foot exceeds member's need and cannot be covered.

The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plan's denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the enrollee's
physician states a K3 foot is medically necessary as the enrollee is a K3 ambulator. However, this is not
consistent with available medical history. The medical records show the enrollee currently uses a wheelchair
and walker. This is not consistent with K3 ambulation. Medicare covers items that meet, but do not exceed, the
member's need. The medical records do not show why the enrollee requires a K3 foot, or why a standard foot
would not meet the enrollee's needs. Therefore, the documentation does not demonstrate that the enrollee is a
K3 ambulator.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say the documentation
provided does not support that the enrollee was a K3 ambulator at the time of the appeal. Medicare rules for
coverage of the requested prosthetic equipment have not been met. Therefore, we decided that the Plan does
not have to pre-approve a flex-walk system (L5981) and multiaxial ankle and hydraulic active dorsiflexion
(L5968) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Ottobock C-leg (L5828, L5845, L5848, L5850,
L5856), Ossur Pro-flex foot ((L5981, L5986), and alignable system (L5920) for the enrollee.

You asked the Plan to pre-approve the requested prosthetic equipment. You say that the requested prosthetic
equipment is medically necessary. The Plan denied your request. The Plan says the records provided do not
support the medical necessity of the prosthetic equipment requested. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
enrollee is a 75-year-old male with peripheral neuropathy and is an above knee amputee. The enrollee
ambulates with a rolling walker and his prosthesis. His condition of peripheral neuropathy causes balance
deficits. The medical records do not support that the enrollee has the functional status of a K3 ambulator. While
enrollee's provider states that enrollee is "expected" to be K3 ambulator, the medical record does not
corroborate this. The enrollee also has several other health conditions that contribute to the enrollee's inability
to be a K3 ambulator.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. 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
requested prosthetic system have been met. Therefore, we decided that the Plan does not have to pre-approve
an Ottobock C-leg (L5828, L5845, L5848, L5850, L5856), Ossur Pro-flex foot ((L5981, L5986), and alignable
system (L5920) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on August 
15, 2023. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that you should only have a 
$5 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 $40 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the in-
network 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 reduce the copayment for a specialist office visit provided on August 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
on August 07, 2023. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you were 
unaware of 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 $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $350 copayment for the myocardial perfusion imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the myocardial perfusion imaging provided on August 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
24, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you did not see a provider. 
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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a specialist 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 a specialist office visit provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 21, 2023, billed with 
procedure codes 97750-GP (4 units) and 97750-GP (2 units). 
 
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 documentation does not support the billed code. 
 
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 97750 is physical performance test or measurement (eg, 
musculoskeletal, functional capacity), with written report, each 15 minutes. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed codes. Our reviewer found that the documentation does not support 
the number of units billed. The procedure code represents "each 15 minutes". The procedure report does not 
include documentation of the additional minutes billed, and therefore cannot be verified. In addition, the 
documentation does not include a signature of treating provider. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 21, 2023, billed with procedure codes 
97750-GP (4 units) and 97750-GP (2 units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 8, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service does not require an authorization. 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 June 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for the "BOA" powered system (L5999) for the
enrollee.

You asked the Plan to provide coverage for this prosthetic equipment. You say that the Plan denied your
request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
"BOA" system is not approved by the Food and Drug Administration (FDA) and is not covered by Medicare.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not provide coverage for
prosthetic equipment that is not FDA approved and/or for providers of prosthetic equipment who cannot accept
Medicare payment.

Based on the information provided regarding this equipment, Medicare rules for coverage of this prosthetic
equipment have been met. Therefore, we decided that the Plan does not have to provide coverage for the
"BOA" powered system (L5999) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound provided on 
August 16, 2023. 
 
You asked the Plan to waive the copayment for an abdominal ultrasound. You say that you do not think that the 
copayment should have 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 a $60 
copayment for Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $60 copayment for an abdominal ultrasound. This item/service falls within the 
Medicare-covered diagnostic radiology 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 abdominal ultrasound provided on August 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable X-ray services provided on July 25, 2023. 
 
You asked the Plan to pay for portable X-ray services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the services at issue have been billed with an incorrect 
POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that POS code 31 should be used with services for 
patients in a Part A-covered stay and POS code 32 should be used with services for beneficiaries in a 
noncovered stay. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable X-ray services have not been met. Specifically, the Plan has documented that the enrollee 
was in a Part A-covered stay on the date of service at issue. The services at issue have not been billed with the 
POS code that reflects the enrollee's situation.  
  Therefore, we decided that the Plan does not have to pay for portable X-ray services provided on July 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 05, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the transportation. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on July 05, 2023.