Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the injection provided on November 23, 2022. We 
also decided that the Plan does not have to fully waive the coinsurance for the injection provided on November 
23, 2022.  
 
You asked the Plan to waive the coinsurance for the injection. You say that the drug is used for hormonal 
treatments. The Plan denied your request. The Plan says that this cost sharing was charged correctly. We decided that the Plan has to reduce the coinsurance for the injection.  
 
You have been asked to pay $99.88 for the injection. Based on the Plan contract you cannot be asked to pay 
more than $98.28, which is 20% coinsurance of the allowed amount ($491.42 allowed amount x 20% = 
$98.28). Therefore, we decided that the Plan has to reduce the coinsurance for the injection provided on 
November 23, 2022.  
 
We also decided that the Plan does not have to fully waive the coinsurance for the injection. 
 
You are responsible to pay 20% coinsurance of the allowed amount for the injection. This item/service falls 
within the Medicare Part B drugs benefit category. 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 fully waive the 
coinsurance for the injection provided on November 23, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare criteria for 
LTACH admission that cannot be accomplished at a lower level of care. The Plan denied your request. The 
Plan says the enrollee does not meet Medicare guidelines for care in an LTACH. 
 
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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be administered at the current facility until they 
are more stable and appropriate for a lower level of care.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable enough for 
transfer and as it would not be clinically advantageous.  
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care office visit provided on 
September 02, 2022. 
 
You asked the Plan to reduce the copayment for the urgent care office visit. You say that you were told the 
copayment was only $40. 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 in-network and out-of-network urgently needed services. 
 
You have been asked to pay a $50 copayment for the urgent care office visit. This item/service falls within the 
in-network and out-of-network 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 reduce 
the copayment for the urgent care office visit provided on September 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chemotherapy. You say that you would like to be seen at City of Hope 
(COH). The Plan denied your request. The Plan says the services are available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chemotherapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower extremity ultrasound provided on November 22, 
2022. 
 
You asked the Plan to pay for a lower extremity ultrasound. You say that you do not agree with the denial of 
this service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a lower extremity 
ultrasound provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code is 
bundled to surgery code 64612. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99213 was billed on the same date of service as minor procedure code 64612. Code 
99213 was not billed with a modifier to allow for separate payment. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99213 billed for date of service August 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation miles. 
 
  You asked the Plan to pre-approve additional transportation miles. You say that you need transportation to this 
appointment because you are trying to have a checkup for laryngospasm and possibly see if you need surgery 
for it as well. You also say that your current doctor referred you to the doctor you have the appointment with 
for the procedure. The Plan denied your request. The Plan says your request for additional mileage is not 
approved because you have exceeded your benefit limit. 
 
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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. The record shows that your request 
exceeds the mileage limit. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
transportation miles.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on September 
7, 2022. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that in previous years you did 
not have to pay for ambulance services. 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 $250 
copayment for ambulance services.  
 
 
 You have been asked to pay a $250 copayment for the ambulance service. 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 waive the copayment for ambulance service 
provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the laser surgery. You say that you were seen in the emergency room for a 
severe burn. You say that you were referred to an outpatient plastic surgeon. You say that you went to another 
provider. You also say that you cannot afford to pay for it. The Plan denied your request. The Plan says there 
was no information provided to support why the services need to be provided out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve laser 
surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you are asking for 
transportation to medical appointments. You also say that you are suffering directly because you are denied 
transportation to medical appointments. The Plan denied your request. The Plan says this request is not covered 
because you have exceeded the benefit limit. 
 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 up to 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomographic angiography (CTA) of chest with 
contrast material and image postprocessing provided on December 17, 2022, billed with procedure code 71275. 
 
You asked the Plan to pay for the CT. You say that the procedure was rendered in the appropriate place of 
service. The Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general policy, the place of service (POS) 
code assigned by the physician/practitioner for the professional component (PC) of a diagnostic service shall be 
the setting in which the enrollee received the technical component (TC) service.  
 
We looked at the file and Medicare rules. The claim reflects the 2-digit place of service (POS) code 22 for on 
campus-outpatient hospital. The member was registered as an inpatient of a hospital during the time of service. 
The appropriate inpatient place of service (POS) code must be used. Based on this information, we decided that 
Medicare rules for coverage of the CT have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomographic angiography (CTA) of chest with contrast material and image postprocessing 
provided on December 17, 2022, billed with procedure code 71275.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 8, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary.  
The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible 
and available and requires authorization for certain services. No medical necessity for an out-of-network 
provider such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that your condition has worsened, and you have 
been hospitalized for one week in December 2022. You also say that you are wondering if you need to change 
your insurance company to get the help you need. The Plan denied your request. The Plan says no supporting 
evidence showing your physician believes you are at high risk for an unplanned hospitalization within the next 
60 days was received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for transition lenses provided on April 21, 2022.
You asked the Plan to pay for transition lenses. You say that transition lenses were medically necessary. The
Plan denied your request. The Plan says your provider did not submit medical records to show transition lenses
were medically necessary. Maximus overturned the Plans denial for a lack of medical records in the file. The
Plan requested a reopen and provided the required medical records.
The Plan is correct in this case. Medicare does not cover routine vision and eyewear services. The Plan offers a
routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules
apply in this case. The Plan covers transition lenses when the medical records confirm a diagnosis of extreme
light sensitivity. This diagnosis is not present in the medical records submitted by your provider. Therefore, we
decided that the Plan does not have to pay for transition lenses provided on April 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not aware that the ambulance was called, therefore you are requesting that the Plan reconsider payment. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 
 The ambulance company did not provide transport services on November 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided internationally for the enrollee.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says only emergency services to make an enrollee stable are covered out of the country. The Plan also required medical records, in English, to determined what can be covered however no medical records were submitted by the providers. Maximus upheld the Plans denial as there were no medical records submitted for review. You then requested an ALJ hearing.
Maximus reviewed to cases submitted by the health plan for services on appeal. Those case numbers were appeal number for inpatient care out of the country from January 1, 2019, to January 31, 2019, and appeal number for various medical services provided out of the country from October 13, 2018, to February 25, 2019. You only submitted an ALJ request for appeal number.
Maximus processed your request and sent the appeal to your ALJ Field office. You did not request an ALJ hearing for case number. Therefore, those records were not sent to the ALJ Field Office.
The ALJ has now remanded the case back to Maximus stating all claims for medical services provided to the enrollee out of the country were not reviewed. Maximus only has jurisdiction to review cases submitted directly by health plan. The Plan submitted two separate cases to Maximus for review. Only one ALJ request was submitted for the inpatient hospital services from January 1, 2019, to January 31, 2019. The dates of service now remanded back to Maximus by the ALJ, October 13, 2018, to February 25, 2019 did not have a valid ALJ request submitted to Maximus, which is why those documents were not submitted to the ALJ.
Maximus has reviewed both cases and found the Plans decision was correct as other than receipts, there were no medical records submitted in English or submitted for the opportunity to be translated to English that would allow the Plan or Maximus to make a coverage determination for emergency services outside of the country. It should also be noted that only emergency services to stabilize an enrollee's condition were covered by the Plan worldwide. Once an enrollee's emergency is stabilized, coverage ends as on-going treatment after the emergency is over would not be covered worldwide. Therefore, based on the records provided in the case files and the lack of medical records for review, Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided internationally for the enrollee.
Please be advised that if you would like to appeal to the ALJ a second time, an ALJ form should be submitted for both case numbers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom orthopedic footwear (L3215). 
 
You asked the Plan to pre-approve custom orthopedic footwear. You say that you need this item. The Plan 
denied your request. The Plan says you do not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that orthopedic footwear is covered in limited 
circumstances.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custom orthopedic footwear have not been met. Therefore, we decided that the Plan does not have 
to pre-approve custom orthopedic footwear (L3215).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99226 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 99226. You say that this is a corrected code. The Plan denied 
your request. The Plan says payment for code 99226 is bundled into payment for code 99219. 
 
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, we have confirmed that code 99226 is a column II code to column I code 99219 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99226 
billed for date of service November 28, 2022.