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

 
We decided that the Plan does not have to adjust the copayments for the chiropractic manipulative treatments 
(98941 x 3) provided from May 17, 2023, through July 5, 2023. 
 
You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $50 
copayment for each Medicare covered chiropractic visit rendered by an out-of-network provider.  
 
 
  
 
 
 
You have been asked to pay $119.37 ($39.79 x 3) for the Medicare covered chiropractic visits rendered by an 
out-of-network provider. This is the Plans allowed amount for these services, which is less than the applicable 
copayments. 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 adjust the copayments for the chiropractic manipulative treatments 
(98941 x 3) provided from May 17, 2023, through July 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance angiography provided on September 26, 2022.

You asked the Plan to waive the copayment for the magnetic resonance angiography. You say that this service was rendered at a hospital because you are claustrophobic, and you need to be anesthetized. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial because there was insufficient information. The Plan requested a reopening and stated you were charged the correct amount based on your contract. The Plan is correct in this case. The Plan has now provided the Evidence of Coverage, which states that you must pay a $175 copayment for each Medicare-covered diagnostic radiology service in an outpatient facility. The Plan also provided your Explanation of Benefits to confirm you were charged a $175 copayment. Your contract with the Plan clearly says that you must pay a $175 copayment for each Medicare-covered diagnostic radiology service in an outpatient facility.

This item/service falls within the Medicare-covered diagnostic radiology service in an outpatient facility 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 magnetic resonance angiography provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint injections (27096).

You asked the Plan to pre-approve bilateral SI joint injections. You say that it has been years since your last injection. The Plan denied your request. The Plan says that the requested injection is not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for bilateral SI joint injections. Our Medical Director states that your low back and upper buttock pain has a radicular component, with radiation into the left hip and anterolateral thigh. In addition, the imaging studies suggest other potential causes of lumbosacral pain, with evidence of moderate canal stenosis, multilevel facet arthropathy, multilevel disc protrusion, and Grade 1 anterolisthesis. Our Medical Director found that your condition does not meet criteria for coverage of bilateral SI joint injections. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral SI joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint injections (27096).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 29, 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 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D1110, 
D0120) provided on April 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation and cleaning 
(D1110, D0120) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on June 
14, 2023. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for urgently needed services. 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 waive the copayment for urgently 
needed services provided on June 14, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on March 09, 2023, to May 19, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were advised 
there would be no copayment for in-network providers. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient 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 copayment you owe is $320 for PT services ($40 per visit x 8 
visits = $320). Therefore, we decided that the Plan does not have to waive the copayment for each physical 
therapy (PT) visit provided on March 09, 2023, to May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the debridement services provided on 
April 13, 2023, to April 25, 2023. 
 
You asked the Plan to pay for the office visit and the debridement services. 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 and the 
debridement services provided on April 13, 2023, to April 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NUEDEXTA. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve NUEDEXTA.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 15, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring and the chronic care management 
provided on May 31, 2023. 
 
You asked the Plan to pay for the remote monitoring and the chronic care management. 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 remote monitoring 
and the chronic care management provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each radiation treatment provided on May 
10, 2023, to May 17, 2023. 
 
You asked the Plan to waive the coinsurance for each radiation treatment. You say that you are being over 
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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for each radiation treatment. 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 amount you owe for each radiation treatment 
is $46.59 ($232.97 allowed amount x 20% = $46.59). The total amount you owe is $93.18 ($46.59 coinsurance 
x 2 treatments = $93.18). Therefore, we decided that the Plan does not have to waive the coinsurance for each 
radiation treatment provided on May 10, 2023, to May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a vacuum assisted suspension system (VASS) (L5981) for the enrollee.

You asked the Plan to provide coverage for a vacuum assisted suspension system (VASS) (L5981). You say that at the time of the appeal, this device was medically necessary for the enrollee. 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 coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a vacuum assisted suspension system (VASS) (L5981). The previous reviewer determined that the provided medical record is sufficient to justify the requested suspension system. The reviewer found that although Medicare policy is technically non-specific about coverage rules for VASS, it does in fact routinely cover it, meaning it cannot be on its face "experimental." The reviewer also found that this system is in the mainstream of standards of prosthetic care. "Therefore, the reviewer found that the requested VASS is medically reasonable and necessary." The Plan has requested a reopen stating there is no compelling clinical justification for VASS, and that the enrollee's physician does not document the medical need for vacuum volume management system. "Prosthetist's claim that VASS is needed is not supported by physician's notes."

The medical records show the enrollee has a medical history that includes diabetes, hypertension, and end-stage renal disease. The enrollee underwent a right transtibial amputation. The enrollee was noted to be a K2 level ambulator. The Plan is correct in this case. The available clinical documentation in the case file does not support that a VASS (L5981) is medically reasonable and necessary for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a vacuum assisted suspension system (VASS) (L5981) have not been met. Therefore, we decided that the Plan does not have to provide coverage for a vacuum assisted suspension system (VASS) (L5981) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical record attestation, the patient screening and the 
home visit provided on June 12, 2023. 
 
You asked the Plan to pay for the medical record attestation, the patient screening and the home 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 medical record 
attestation, the patient screening and the home visit provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 01, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing 
facility care provided on June 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network specialist office visit 
provided on May 04, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network specialist office visit. You say that you 
disagree with the coinsurance. 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 50% 
coinsurance for out-of-network specialist office visit. 
 
You have been asked to pay 50% coinsurance for out-of-network specialist office visit. This item/service falls 
within the out-of-network specialist office visit 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 out-of-network specialist office visit provided on May 04, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on June 30, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you paid 
$120 copayment and would like to be reimbursed. 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 outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 magnetic resonance imaging (MRI) provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections, radiological exams and related services provided 
on March 28, 2023. 
 
You asked the Plan to pay for injections, radiological exams and related services. You say that this service is 
supported in the records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections, radiological 
exams and related services provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and removal of impacted tooth (D7230, D7140) 
provided on April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction and removal of impacted tooth (D7230, D7140) provided on April 18, 2023.