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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 22, 
2023, to May 26, 2023, by an OON provider.  
 
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 the 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 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 subsequent nursing facility care provided on 
May 22, 2023, to May 26, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and 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 an office visit provided 
on December 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the Intracept procedure. You say that the surgery is medically necessary and that the enrollee meets all the criteria. The Plan denied your request. The Plan says that the records do not show that the enrollee failed non-surgical medical management, including physical therapy.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for the Intracept procedure. Our Medical Director states that provided records in this case document disc bulging, facet arthrosis and other degenerative changes on spinal imaging which may be the cause of the patient's back pain. Provided records in this case do not document the Intracept procedure meets Medicare criteria for safe, effective, reasonable, and necessary. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the Intracept procedure.
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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies provided on May 31, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the medical supplies. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical supplies provided on May 31, 2023, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 30, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory service provided on March 30, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on April 
06, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that this was billed 
inaccurately. 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 in and out-of-network services obtained from a specialist. 
 
You have been asked to pay a $45 copayment for a new patient office visit. This item/service falls within the in 
and out-of-network services obtained from a specialist 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 new patient office visit provided on April 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 29, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you do not feel 
liable for the copayment because you were misdiagnosed. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care 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 emergency room 
(ER) visit provided on April 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 10, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for one-way trip Medicare-covered ambulance services. 
 
You have been asked to pay a $350 copayment for ambulance services. This item/service falls within the one-
way trip Medicare-covered 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. However, since the allowed amount is less than the standard 
copayment, you only owe $308.77. Therefore, we decided that the Plan does not have to waive the copayment 
for ambulance services provided on May 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 23, 2022, to 
December 08, 2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on November 23, 2022, to December 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and
electronic connection (E2311).
You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that
these items are medically necessary. The Plan denied your request. The Plan says that that the upgraded
electronics are not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness and electronic connection. Our Medical Director states that provided records document that
you have 3-/5 bilateral upper extremity wrist and hand strength, with normal wrist and hand posture and you
are reported to be independent with eating, thus indicating you have adequate upper extremity strength and
function to operate the wheelchair's power options with their own switches. Our Medical Director found that
your condition does not meet criteria for coverage of an expandable controller, harness and electronic
connection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness
(E2313), and electronic connection (E2311).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 21, 2023, to May 22, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were taken to 
the ER against your will and should not be liable for the copayment applied. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency care 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 
emergency room (ER) visit provided on May 21, 2023, to May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on August 10, 2022.
You asked the Plan to pay for the Guardant360 testing. You say that the testing was medically necessary. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on August 10, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 93005 and 94761 for date of service November 15, 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 Plan's denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan notes that code 93005 has a status indicator of Q1 according to "Addendum B - OPPS Payment by HCPCS Code for CY 2022."
The Plan also states that code 99285 was billed on the same date of service with a revenue code of 450 which according to the I/OCE Quarterly Release Files has a status indicator of "V" (clinic or emergency department visit). Therefore, code 93005 is not separately payable according to Medicare Claims Processing Manual Chapter 4 - Part B Hospital, Section 10.4, C, 2.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, based on the Medicare billing guidelines, code 93005 is not allowed to be billed or paid separately in this case and therefore errors out the claim in its entirety. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93005 and 94761 for date of service November 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH services requested does not meet the 
criteria required for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The requested service cannot be recommended as 
the elements of the coverage rules are not satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on July 15, 2022.
You asked the Plan to pay for the ambulance services. You say that these were ET3 ambulance services, and the "W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is an invalid destination modifier on ambulance claims. Maximus overturned the Plan's denial. The Plan requested a reopening and states that the modifier "W" is not valid for this claim. The Plan is correct in this case. They have provided a Medicare rule showing that the ET3 Model applies only to the traditional Medicare-Fee-for-Service program and does not apply to Medicare Advantage plans. The enrollee was covered by a Medicare Advantage plan when these services were provided. Therefore, this claim was not filed with an appropriate modifier.
Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided to the enrollee on July 15, 2022.
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 May 30, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you did not 
expect to pay a 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 $180 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $180 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 May 30, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 13, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on January 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 19, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you disagree 
with the copayment applied. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $350 copayment for a computed tomography (CT) scan. 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 
computed tomography (CT) scan provided on May 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy provided on December 05, 
2022. 
 
You asked the Plan to pay for esophagogastroduodenoscopy. 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 
esophagogastroduodenoscopy provided on December 05, 2022.