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

 
We decided that the Plan does not have to pay for the laboratory services provided on April 25, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this is a covered service and should be paid. 
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 laboratory services 
provided on April 25, 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 not clear. 
 
  
 
 
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 a facility visit provided on April 20, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior 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 a facility visit provided 
on April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spinal Simplicity Minuteman G5 MIS Fusion plate to 
L4-L5 (22840, 22612). 
 
You asked the Plan to pre-approve Spinal Simplicity Minuteman G5 MIS Fusion plate to L4-L5. You say that 
this service was medically necessary. The Plan denied your request. The Plan says medical studies haven't 
proven this service/item is helpful for treatment of spinal stenosis. 
 
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 Spinal Simplicity Minuteman G5 MIS 
Fusion plate to L4-L5. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the Minuteman device is 
experimental. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spinal Simplicity Minuteman G5 MIS Fusion plate to L4-L5 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Spinal Simplicity Minuteman G5 MIS Fusion 
plate to L4-L5 (22840, 22612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the diabetic supplies (A4224, A4225) 
provided on March 21, 2023. 
 
You asked the Plan to reduce the cost share for the diabetic supplies (A4224, A4225). You say that you feel 
you have been over charged for your part of the items you received. 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. The annual deductible applies. You also have an $800 deductible which 
applies to certain items and services. The Plan deductible applies to durable medical equipment (DME) and 
related medical supplies. 
 
You have been asked to pay $64.11 for the diabetic supplies (A4224, A4225) ($641.10/allowed amount x 10% 
= $64.11). This item/service falls within the durable medical equipment (DME) and related 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 reduce the cost share for the diabetic supplies (A4224, 
A4225) provided on March 21, 2023.  
 
You have been asked to pay $432.25 for the diabetic supplies (A4224, A4225) toward your deductible. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible which 
applies to the durable medical equipment (DME) and related medical supplies. The record shows you paid 
$137.34, toward your deductible, on date of service March 3, 2023, and $230.41, toward your deductible, on 
date of service April  21, 2023. That means you only paid $367.75 toward your deductible ($137.34 + $230.41 
= $367.75 - $800 = $432.25/balance). The This cost sharing is a contractual obligation that had not been met at 
the time you received supplies on March 21, 2023. Therefore, we decided that the Plan does not have to waive 
the cost share for the supplies provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on May 18, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that the services 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 chronic care 
management services provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the office visit provided on April 18, 
2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the office visit. You say that you have not had any problems 
or reimbursement payment issues with this provider before. The Plan denied your request. The Plan says this 
service was 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 provide reimbursement for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan has a POS option to cover 
certain out-of-network services. The Plan contract also says that authorization rules apply for out-of-network 
physician services. 
 
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 provide reimbursement for these 
items/services. Therefore, we decided that the Plan does not have to provide reimbursement for the office visit 
provided on April 18, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT) provided on 
March 20, 2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment (CMT). You say that the services 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 chiropractic 
manipulative treatment (CMT) provided on March 20, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that the service was not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided the correct Evidence of Coverage. Therefore, we 
decided that the Plan has to pay for the laboratory services provided on August 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on June 
27, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you did not think to see if 
the laboratory was 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 $5 
copayment for in-network outpatient diagnostic lab services provided at a free-standing laboratory. 
 
You have been asked to pay a $5 copayment for the laboratory services. This item/service falls within the in-network outpatient diagnostic lab services provided at a free-standing laboratory 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 the laboratory is in-
network, and the in-network copayment was correctly applied. Therefore, we decided that the Plan does not 
have to waive the copayment for the laboratory services provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (prostate) provided on May 22, 2023. 
 
You asked the Plan to pay for oncology (prostate). You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for oncology (prostate) 
provided on May 22, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission was medically necessary for the enrollee. The Plan denied your request. The Plan says 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The enrollee was a then 76-year-old woman with a medical history that included hypertension, diabetes, COPD, and chronic kidney disease. She was admitted to the hospital on June 5, 2023, with tongue swelling and angioedema. The enrollee was diagnosed with angioedema of the tongue, hypertension, and metabolic acidosis. It was noted that the enrollee was non-ambulatory and was max assist for bed, chair, and toilet transfers. The final discharge setting was noted to be custodial or long-term care. The Plan is correct in this case. The documentation does not support that at the time of the appeal, the enrollee required daily skilled nursing or daily skilled therapy services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 12, 2022, to October 11, 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 for insufficient claim information. The Plan requested a reopen and provided additional information. The Plan noted that the date span billed was inappropriate. The patient discharge code of 6 in relation to the date span reported is in error. The "06" discharge status code should only be used to indicate a shortened period claim due to "scenario A" or "scenario B" in Medicare Claims Processing Manual, chapter 10, Section 10.1.15.
In this case the claim shows the provider billed for the full 30-day period with no discharge, therefore scenario A does not apply. Scenario B also would not apply because the enrollee did not transfer to a different home health agency based on the subsequent claim submitted by the same provided for dates October 12, 2022, to November 09, 2022. As neither, apply, the 06-discharge status is inappropriate.
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, this claim could not be paid as billed due to an error with the reported discharge status code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 12, 2022, to October 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each x-ray provided on June 29, 2022, to 
July 27, 2022. 
 
You asked the Plan to waive the copayment for each x-ray. You say that you want to appeal the amount being 
charged. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for each x-ray. 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. The total you owe is $56.52 ($28.26 copayment x 2 visits = 
$56.52). However, since the allowed amount is less than the standard copayment, you only owe $56.52. 
Therefore, we decided that the Plan does not have to waive the copayment for each x-ray provided on June 29, 
2022, to July 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on June 
01, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you are on a fixed 
income, and you never had to pay for these services in the past. 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 $100 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $100 copayment for the abdominal ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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, since the allowed amount is less than the standard 
copayment, you only owe $94.09. Therefore, we decided that the Plan does not have to waive the copayment 
for the abdominal ultrasound provided on June 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the knee replacement provided on June 27, 
2023. 
 
You asked the Plan to waive the copayment for the knee replacement. 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 $270 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $270 copayment for the knee replacement. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 knee replacement provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 02, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on June 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) denervation (radiofrequency 
ablation (RFA) (64625). 
 
You asked the Plan to pre-approve SIJ denervation. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called RFA) is not 
considered reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SIJ denervation have not been met. Therefore, we decided that the Plan does not have to pre-
approve sacroiliac joint (SIJ) denervation (radiofrequency ablation (RFA) (64625).