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

 
We decided that the Plan does not have to waive the coinsurance for a screening mammogram, and screening 
digital breast tomosynthesis provided on November 23, 2022. 
 
You asked the Plan to waive the coinsurance for a screening mammogram, and screening digital breast 
tomosynthesis. You say that you were told that you would get one annual mammogram. 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 40% 
coinsurance for out-of-network covered screening mammograms. 
 
You have been asked to pay 40% coinsurance for a screening mammogram, and screening digital breast 
tomosynthesis. This item/service falls within the out-of-network covered screening mammograms 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 $28.96 ($72.41 allowed amount x 40% = $28.96). Therefore, we decided that the Plan does not have to 
waive the coinsurance for a screening mammogram, and screening digital breast tomosynthesis provided on 
November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that tissue mobility and location of the lesion make image-
guided radiation therapy medically necessary. The Plan denied your request. The Plan says that it is not 
medically necessary and that the quantity requested is beyond the allowed number of units. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but is not necessary. Using daily 
IGRT for a technology for which the need has not been established is not necessary. This would not be 
furnished in accordance with accepted standards of medical practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IGRT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service April 11, 
2023. 
 
You asked the Plan to pay for procedure code S2900. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve 24 additional one-way routine transportation trips. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says further trips are not covered beyond the plan benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 22 of 
the 24 one-way routine transportation trips allowed by the Plan benefit. Once you have used all 24 one-way 
trips, further trips are not covered by the Plans supplemental benefit or Medicare. Therefore, we decided that 
the Plan does not have to approve 24 additional one-way routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound diagnostic breast imaging provided on  
February 8, 2022. 
 
You asked the Plan to pay for the ultrasound diagnostic breast imaging. The Plan denied your request. The Plan 
says the primary payer will need to review the services for payment consideration before the Plan can consider 
the claim for payment consideration as secondary payer. The Plan contacted the provider and successfully 
relayed the information.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider and successfully relayed the information. As the secondary insurer, the Plan cannot be held 
responsible for ultrasound diagnostic breast imaging until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for ultrasound diagnostic breast imaging 
provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by an in-network 
provider on January 3, 2023.  
 
You asked the Plan to waive the deductible for the office visit. You say that you previously had this service and 
was not charged as much. 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. Your 
contract with the Plan says that there is a $400 in and out-of-network deductible which applies to the office 
visit. 
 
 You have been asked to pay a $125.38 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 in and 
out-of-network deductible which applies to physician/practitioner services, including doctors office visits. This 
cost sharing is a contractual obligation that had not been met at the time the office visit was provided on 
January 3, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the office visit 
provided by an in-network provider on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by the 
family practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied 
your request. The Plan says this item is considered experimental and investigational. There is insufficient 
evidence of its effectiveness in those with stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle orthotic (L1971) provided to the enrollee on
November 2, 2022.
You asked the Plan to pay for the ankle orthotic. You say that you want to appeal this denial. The Plan denied
your request. The Plan says the patient's medical record must contain sufficient documentation of the patient's
medical condition to substantiate the necessity for the type and quantity of items ordered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid
physician order, proof of delivery and relevant medical records which support medical necessity.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The medical records provided do not discuss the need for this item. The record shows that the Plan
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the
Plan does not have to pay for the ankle orthotic (L1971) provided to the enrollee on November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 20, 2022, 
to March 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 20, 2022, to 
March 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing exam provided on March 27, 2023. 
 
You asked the Plan to waive the copayment for hearing exam. 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 $25 
copayment for hearing services. 
 
You have been asked to pay a $25 copayment for hearing exam. This item/service falls within the hearing 
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 hearing exam provided on 
March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the iron sucrose injection, the saline injection and the administrations provided on October 25, 2022, and November 8, 2022.
You asked the Plan to waive the coinsurance for the injections and administrations. You say that you were not given multiple injections on the same date. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus 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 20% coinsurance for Medicare Part B covered drugs and administration.
You have been asked to pay a 20% coinsurance for the injections and administration. This item/service falls within the Medicare Part B covered drugs and administration 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 iron sucrose injection, the saline injection and the administrations provided on October 25, 2022, and November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital inpatient or observation care (99222) provided to the enrollee on October 6, 2022.
You asked the Plan to pay for these services. You say that the enrollee was treated twice and was seen by different specialists. The Plan denied your request. The Plan says that this code was reported within 3 days of a prior initial hospital inpatient or observation care service 99222 for the same diagnosis and by a provider with the same specialty.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for the initial hospital inpatient or observation care (99222) provided to the enrollee on October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services provided on March 02, 
2023. 
 
You asked the Plan to pay for the molecular pathology services. You say that this is a covered Medicare 
benefit. 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 molecular pathology 
services provided on March 02, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each infusion therapy service provided on 
March 18, 2023, to March 30, 2023. 
 
You asked the Plan to waive the copayment for each infusion therapy service. You say that you would like the 
cost sharing to be lower. 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 Medicare-covered services provided in an outpatient hospital. 
 
You have been asked to pay a $150 copayment for each infusion therapy service. This item/service falls within 
the Medicare-covered services provided in an outpatient hospital 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 amount you owe is $1950 ($150 
copayment x 13 services = $1950). Therefore, we decided that the Plan does not have to waive the copayment 
for each infusion therapy service provided on March 18, 2023, to March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services, 
monthly, provided on March 1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ESRD related services. You say that this claim should be reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 end-stage renal disease (ESRD) related 
services, monthly, provided on March 1, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0801). 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says it is not 
shown that you need the scooter to allow you to move around your home. The Plan also says a scooter is not 
covered when the main purpose is to improve mobility outside your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement scooter. 
 
You asked the Plan to pre-approve a replacement scooter. You say that you need something dependable to be 
able to get around. You also say that you cannot wait until the end of the year for this to be repaired and you 
need the chair replaced. The Plan denied your request. The Plan says the device requested is a backup chair and 
is being requested for use only outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a replacement scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 7, 2022. 
 
You asked the Plan to pay for the physician's services. You say that you have been seeing this provider for 30 
years and the Plan has always paid for the services. The Plan denied your request. The Plan says while you can 
get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except 
for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you go to a 
provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services 
you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network infusion into a vein provided 
on March 22, 2023. 
 
You asked the Plan to waive the copayment for an in-network infusion into a vein. You say that you want this 
to be reviewed. 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 $300 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 You have been asked to pay the allowed amount of $231.17 which is less than the $300 copayment for an in-
network infusion into a vein. This item/service falls within the Medicare-covered surgery or other services 
provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and 
physician or surgical charges 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 in-
network infusion into a vein provided on March 22, 2023.