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

 
We decided that the Plan does not have to pay for the office visit provided on November 29, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that the provider is authorized to provide 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 office visit provided on November 29, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cardiac rehab provided on March 15, 
2023, to March 29, 2023. 
 
You asked the Plan to waive the copayment for each cardiac rehab. You say that you would like to be 
reimbursed and to continue with no 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 $15 
copayment for cardiac rehabilitation services. 
 
You have been asked to pay a $15 copayment for each cardiac rehab. This item/service falls within the cardiac 
rehabilitation 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. The total you owe is $240 ($15 copayment x 16 visits = $240). Therefore, we decided that 
the Plan does not have to waive the copayment for each cardiac rehab provided on March 15, 2023, to March 
29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical simulator supplies (A4595) provided to the enrollee on October 2, 2022.
You asked the Plan to pay for the electrical simulator supplies. You say that this should be covered. The Plan denied your request. The Plan says that the provider did not submit any evidence that they have been contacting the member before shipping additional supplies.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the electrodes being dispensed. Based on this information, we decided that Medicare rules for coverage of the electrical simulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for the electrical simulator supplies (A4595) provided to the enrollee on October 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Check test strips.
You asked the Plan to pre-approve Accu-Check test strips. You say that you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says that their preferred brand is OneTouch.
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 Accu-Check test strips have been met.
There are no medical records provided to indicate you cannot use the Plan's preferred products. The file indicates that the Plan has requested medical records from your physician multiple times without response. Therefore, we decided that the Plan does not have to pre-approve Accu-Check test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam provided on February 2, 2023.
You asked the Plan to pay for the routine eye exam. You say that the visit was not billed as a routine eye exam as you requested. The Plan denied your request. The Plan says that the benefit has been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided an Explanation of Benefits to show your benefit was exhausted on this date of service. The Plan is correct in this case. The Plan has shown proof they covered a routine eye exam on March 11, 2022, which is less than 12 months before the exam you received on February 2, 2023. Therefore, we decided that the Plan does not have to pay for the routine eye exam provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 CDx testing (81479) provided to the enrollee on November 16, 2021.
You asked the Plan to pay for the Guardant360 CDx testing. You say that this test was medically necessary and was reported appropriately. The Plan denied your request.
The Plan says that they have correctly denied the claim for payment as the provider did not bill with one of the recommended procedure codes for Z-code ZB1CW. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. The Z-code on the claim is not listed as valid for the CPT code billed. Based on this information, we decided that Medicare rules for coverage of the Guardant360 CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 CDx testing (81479) provided to the enrollee on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services billed under code 76000.
You asked the Plan to pay for this claim as billed. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met.
Maximus partially overturned the Plans denial. The Plan requested a reopen and noted that the only code in question was code 76000. The Plan provided documentation to show the other codes reviewed were addressed and or paid on other claims.
The Plan follows Medicare rules. Medicare rules say that A/B Medicare Administrative Contractors (MACs) (B) may not pay for the technical component (TC) of radiology services furnished to hospital patients. In this case, the enrollee was in a facility at the time of service. Therefore, we decided that the Plan does not have to pay for the services described by procedure code 76000-TC-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital services provided to the enrollee from March 20, 2022, through March 24, 2022, and February 19, 2023, through February 23, 2023.
You asked the Plan to waive the copayments for the inpatient hospital services. You say that you do not agree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially dismissed this appeal. The Plan confirmed the enrollee has remained a member of the Plan for both dates of service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment per day, days 1-4 of Inpatient hospital care for the 2022 year and a $325 copayment per day, days 1-4 for Inpatient hospital care for the 2023 year. The enrollee has been asked to pay a $400 copayment for the dates of March 20, 2022, through March 24, 2022 and a $1,300 copayment for the February 19, 2023, through February 23, 2023 inpatient hospital services. This item/service falls within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the inpatient hospital services provided to the enrollee from March 20, 2022, through March 24, 2022, and February 19, 2023, through February 23, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cardiac imaging, medical supplies, and
drug injection provided on June 9, 2022.
You asked the Plan to waive the coinsurance for the cardiac imaging, medical supplies, and drug injection. You
say that this provider should be in-network. The Plan denied your request. The Plan says this cost sharing was
charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated
that Maximus did not apply the correct criteria.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for out-of-network drugs covered under Medicare Part B, out-of-network diagnostic radiology services and out-of-network medical supplies. You have been asked to pay a 50% coinsurance for the cardiac imaging, medical supplies, and drug injection. This items/services fall within the out-of-network drugs covered under Medicare Part B, out-of-network diagnostic radiology services and out-of-network medical 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 coinsurance for the cardiac imaging, medical supplies, and drug injection provided on June 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on July 21, 
2021. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you cannot afford this 
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 ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance service. 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 
service provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care office visit provided on 
July 14, 2023. 
 
You asked the Plan to reduce the copayment for the urgent care office visit. You say that you were told there 
would only be a $10 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for the urgent care office visit. This item/service falls within the 
urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the urgent 
care office visit provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
08, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this office visit was 
unnecessary and neither you nor the Plan should pay for it. 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 specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist 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 the specialist office visit provided on May 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device. 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that this device is medically necessary 
due to progressively worsening heart failure. The Plan denied your request. The Plan says this device is 
considered experimental. 
 
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 Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of an ankle orthosis. 
 
You asked the Plan to pre-approve ankle orthosis. You say that foot sores and alignment issues are not good for 
the enrollee's health and function. The Plan denied your request. The Plan says the enrollee's current ankle 
orthosis is less than 5 years old and the record does not show irreparable damage. 
 
The Plan follows Medicare rules. Medicare rules state that replacement of durable medical equipment is not 
covered within the reasonable useful lifetime of the equipment except in cases of loss or irreparable damage 
due to a specific accident or natural disaster. 
 
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 ankle orthosis. Our reviewer says that 
the enrollee does not meet criteria for replacement of the ankle orthosis. Our physician reviewer found the 
documentation does not indicate that there has been loss or irreparable damage due to a specific accident or natural disaster. The enrollee's current orthosis is under 5 years old and damaged from use. Replacement due to 
wear is not covered during the reasonable useful lifetime of the equipment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ankle orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve replacement of an ankle orthosis.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted evaluation and management service (99499). 
 
You asked the Plan to pre-approve an unlisted evaluation and management service. You say that you are 
requesting reconsideration and have submitted medical records for review. The Plan denied your request. The 
Plan says the records do not show that your doctor is specifically referring you to the program you requested. 
 
The Plan must follow Medicare rules. Medicare rules say that your PCP must give approval in advance for 
services, before you can use other providers in your plan network such as specialists.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an unlisted evaluation and management service have not been met. Specifically, your PCP has not 
submitted a referral approving your use of another provider and/or specialist. Therefore, we decided that the 
Plan does not have to pre-approve an unlisted evaluation and management service (99499).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pigmented Lesion Assay (PLA) (0089U). 
 
You asked the Plan to pay for the PLA. You say that this service was medically necessary. The Plan denied 
your request. The Plan says criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the PLA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the PLA is considered experimental/investigational. Therefore, it is not considered medically necessary. 
 
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 PLA have not been met. Therefore, we decided that the Plan does not have 
to pay for the Pigmented Lesion Assay (PLA) (0089U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 
30, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you are being charged a 
duplicate copayment for dropping off a sample on a different day. 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 in-network outpatient diagnostic tests and therapeutic services. 
 
You have been asked to pay a $20 copayment for the laboratory services. This item/service falls within the in-
network outpatient diagnostic tests and therapeutic 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. The Plan contract says that outpatient laboratory 
copayments are applied per day services are provided. Therefore, we decided that the Plan does not have to 
waive the copayment for the laboratory services provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service March 4, 2023. 
 
You asked the Plan to pay for code 99233. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says code 99233 is not supported by the medical record. The actual 
date of service cannot be verified in the medical record. 
 
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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
 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 code 99233. Our reviewer says that the medical records do 
not support the billing of code 99233. Our reviewer found the medical documentation provided does not 
support the level of coding. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service March 4, 2023.