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

 
We decided that the Plan does not have to pay for the device evaluation provided on January 01, 2023. 
 
You asked the Plan to pay for the device evaluation. 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 device evaluation 
provided on January 01, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on May 16, 2023. 
 
You asked the Plan to pay for home visit. 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 visit provided on 
May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Heelex low-dose radiation therapy for the enrollee.

You asked the Plan to pre-approve Heelex low-dose radiation therapy. You say that these services are medically necessary. The Plan denied your request. The Plan says that the use of radiation therapy in the treatment of osteoarthritis is not considered an acceptable practice.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Heelex low-dose radiation therapy. Our Medical Director states that the telehealth consult documents that enrollee was diagnosed by his provider with osteoarthritis of the right second toe. The enrollee reported that he has a hammer toe on the second toe which causes a significant amount of pain. Surgical repair was recommended, but the enrollee was unable to have downtime for recovery. The enrollee has tried icing, stretching, resting, medication, and different shoe gear and arch supports. No abnormal exam findings were reported. The enrollee wanted to try a non-invasive treatment modality with Heelex.

The documentation is insufficient to support that Heelex low-dose radiation therapy is medically reasonable and necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of Heelex low-dose radiation therapy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Heelex low-dose radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Heelex low-dose radiation therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluations provided on May 09, 2023, to 
June 20, 2023. 
 
You asked the Plan to pay for the home visit evaluations. 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 home visit 
evaluations provided on May 09, 2023, to June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nebulizer, with compressor provided on June 06, 2023. 
 
You asked the Plan to pay for nebulizer, with compressor. 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 nebulizer, with 
compressor provided on June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2023. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an attachment replacement and implant /abutment supported 
removable denture (D6091, D6110) provided on June 7, 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 
attachment replacement and implant /abutment supported removable denture (D6091, D6110) provided on June 
7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ambulance transportation provided on 
April 24, 2023. 
 
You asked the Plan to reduce the copayment for an ambulance transportation. You say that you would like the 
claim to be reprocessed at the in-network benefit level. 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 $330 
copayment for ambulance services. 
 
You have been asked to pay a $330 copayment for an ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for an 
ambulance transportation provided on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable gaseous oxygen system rental. 
 
You asked the Plan to pre-approve a portable gaseous oxygen system rental. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 a portable gaseous oxygen system 
rental Our reviewer says that the documentation supports that the requested device is medically reasonable and necessary. Our physician reviewer found the enrollee has a documented 6 minute walk test where desaturation 
occurred 2 mins into testing. The medical necessity and rationale are reasonable and the enrollee's saturation on 
6 minute walk test in documentations shows desaturation to 88%. Therefore, the enrollee meets criteria for the 
requested device. 
 
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 portable gaseous oxygen system rental have not been met.  Therefore, we 
decided that the Plan has to pre-approve a portable gaseous oxygen system rental.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29580 and 29581 rendered from May 17, 
2023, to May 22, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 29580: 
 
Strapping; Unna boot  
CPT 29581: 
 
Application of multi-layer compression system; leg (below knee), including ankle and foot 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 29580, the 
medical record describes debridement and casting/dressing performed same anatomical area during same 
session. In this case, when both a debridement is performed and an Unna boot is applied, only the debridement 
may be reimbursed. If only an Unna boot is applied and the wound is not debrided, then only the Unna boot 
application may be eligible for reimbursement. 
 
In terms of CPT 29581, the medical record describes debridement and casting/dressing performed on the same 
anatomical area during the same session. In this case, The National Correct Coding Initiative (NCCI) Policy 
Manual for Medicare Services Chapter 4, section G states that debridement codes (11042-11047, 97597) 
should not be reported with codes 29580, 29581 for the same anatomic area. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 29580 and 29581 rendered from May 17, 2023, to May 22, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.

You asked the Plan to pre-approve Evenity. You say that the enrollee would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the step therapy requirements have not been met. Maximus overturned the Plan's denial because there was insufficient information in the case file. The Plan requested a reopening and stated that step therapy criteria have not been met and provided their Medicare Part B preferred drug list.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Evenity. Our reviewer says that Evenity is not medically reasonable and necessary for the enrollee in this case. The Plan requires a trial of drug Prolia or Reclast before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Evenity. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), intraoral imaging (D0220/D0230), and 
the topical application of fluoride varnish (D1206) provided on July 10, 2023. 
 
You asked the Plan to pay for D1110, D0230, and D1206. You say that you were unaware that you would be 
charged for these services. The Plan denied your request. The Plan says the denied dental services are not 
covered 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 prophylaxis (D1110), intraoral imaging (D0220/D0230), and the topical application of fluoride varnish 
(D1206) provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 06, 2023. 
 
You asked the Plan to pay for laboratory 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 laboratory services 
provided on June 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital inpatient or observation discharge day management 
provided on August 01, 2023. 
 
You asked the Plan to pay for hospital inpatient or observation discharge day management. 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 hospital inpatient or 
observation discharge day management provided on August 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 31, 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 May 31, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound provided on October 11, 2022, and the magnetic resonance imaging (MRI) provided on November 7, 2022.

You asked the Plan to waive the copayments for the ultrasound and MRI. You say that you were not informed of the copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated that the ultrasound was actually a diagnostic radiology service. The Plan is correct in this case.

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 $375 copayment for each Medicare-covered diagnostic radiology service other than CT scans.

You have been asked to pay a copayment for the ultrasound and a copayment for the MRI. These services fall within the Medicare-covered diagnostic radiology service other than CT scans benefit category. This means that you have been asked to pay less than the copayment 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 copayments for the ultrasound provided on October 11, 2022, and the magnetic resonance imaging (MRI) provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each radiation physics consultation 
provided on May 10, 2023, to May 17, 2023. 
 
You asked the Plan to reduce the coinsurance for each radiation physics consultation. You say that you 
disagree with the cost share. 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 physics consultation. 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 
treatment is $36.49 ($182.47 allowed amount x 20% = $36.49). The total amount you owe is $72.98 ($36.49 
coinsurance x 2 treatments = $72.98). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for each radiation physics consultation provided on May 10, 2023, to May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network outpatient laboratory visit 
provided on May 17, 2023. 
 
You asked the Plan to waive the copayment for an in-network outpatient laboratory visit. You say that this is an 
outpatient service, you were not inpatient at the time of this visit. Please correct billing 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 outpatient hospital lab services. 
 
You have been asked to pay a $50 copayment for an in-network outpatient laboratory visit. This item/service 
falls within the outpatient hospital lab 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 an in-network outpatient laboratory visit provided on May 17, 2023.