Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve home health skilled nursing services. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing services. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation of a skilled need that requires the three denied home health 
skilled nursing visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an ultrasound guided left hip injection. 
 
You asked the Plan to pre-approve an ultrasound guided left hip injection. You say that the services are 
necessary. The Plan denied your request. The Plan says that medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 an ultrasound guided left hip injection. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the pain management physician documents that the use of ultrasound is 
necessary due to the proximity of the lesser trochanter to the femoral artery, vein, and nerve. Ultrasound 
guidance is medically reasonable and necessary for injections in which the entrance of a needle into the area 
occupied by the bursa is associated with potential risk of injury to neurovascular structures, such as 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 an ultrasound guided left hip injection have been met. Therefore, we decided 
that the Plan has to pre-approve an ultrasound guided left hip injection.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the coinsurance charged for genetic testing provided 
on October 11, 2019. 
 
You asked the Plan to waive or reduce this coinsurance. You say that no one told you the cost would be this 
high. The Plan denied your request. The Plan says this cost share was charged at the in network rate based on 
the testing provided. 
 
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 genetic testing.  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 or reduce the coinsurance charged for genetic 
testing provided on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on January 6, 
2020. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you received an approved pre-
authorization for the maxillary partial denture. You also say that because the Plan gave the dentist a pre-
authorization for this service, it should be covered. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. 
 
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. Although the maxillary partial denture was approved by the Plan on 
December 5, 2019, the pre-authorization states that it is not a guarantee of payment and is subject to conditions, 
including allowances indicated may vary if plan benefits change prior to the performance of the service. Your 
2020 Plan benefits no longer cover the maxillary partial denture (D5213). Therefore, we decided that the Plan 
does not have to pay for the maxillary partial denture (D5213) provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 27, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the member's primary care physician did not refer these services. 
 
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 has network providers 
available who can provide 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 lab services provided on April 27, 2020 by an out 
of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services (99202, J8499) 
provided January 4, 2020. 
 
You asked the Plan to waive the copayment for the Emergency Room Services. You say that you should only 
have to pay the urgent care copayment. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 the Emergency Room Services. The Emergency Room 
Services 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 Emergency Room Services (99202, J8499) provided January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
December 30, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide 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 out of network physician services provided to the enrollee on 
December 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided to the enrollee from December 18, 2017 to 
December 31, 2017. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says S codes (temporary codes) are used to report drugs, services and supplies 
for which there are no national codes. These codes are primarily used by private insurers for claim processing, 
policies or programs. These codes are not payable by Original Medicare (OM). According to the CMS National 
Physician Fee Schedule (NPFS) code S9328 is listed with a status "I". All codes published on the NPFS by the 
Centers for Medicare and Medicaid Services (CMS) are assigned a status code. The status code indicates 
whether the code is separately payable if the service is covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the code reported, S9328, is not covered 
for Medicare purposes. Therefore, we decided that the Plan does not have to pay for services provided to the 
enrollee from December 18, 2017 to December 31, 2017.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine Pad 5%. 
 
You asked the Plan to pre-approve Lidocaine Pad 5%. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Lidocaine Pad 5%.  
 
Benefits for Lidocaine Pad 5% 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy for rectal adenocarcinoma. 
 
You asked the Plan to pre-approve radiation therapy for rectal adenocarcinoma. You say that the services are 
necessary. The Plan denied your request. The Plan says that medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 radiation therapy for rectal 
adenocarcinoma. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the case records did adequately demonstrate the need for 
intensity modulated radiation therapy (IMRT) using plausible dosimetric evidence (i.e. to what extent IMRT 
reduced the dose-volume exposure of critical normal tissues). This is important in justifying the need for IMRT 
in clinical scenarios (such as this case) for which IMRT is not standard. IMRT will almost always reduce the 
dose to critical structures- the relevant question is to what extent it does so, and is that reduction clinically 
meaningful to reduce toxicity risks. There is documentation that a conventional 3D conformal plan was or 
would be unacceptable. IMRT would be considered to be furnished in accordance with accepted standards or 
care and meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy for rectal adenocarcinoma have been met. Therefore, we 
decided that the Plan has to pre-approve radiation therapy for rectal adenocarcinoma.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) provided on March 23, 2020. 
 
You asked the Plan to pay for the crown. You say that a Plan representative told you that you have $500 to 
spend per calendar year on any dental procedures. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 the crown 
(D2750) provided on March 23, 2020.  
 
Your complaint about being given misinformation by the Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on April 17, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide 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 physician services provided to the enrollee on April 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 6, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim history shows member was in an inpatient hospital visit from March 30, 2020 
through April 07, 2020. CPT code 85060 was denied for inappropriate POS for physician interpretation. 
Review of the claim shows the billed POS is 23 (emergency room hospital). The PC/TC indicator of CPT code 
85060 is 8 identifies payment may not be made if furnished to hospital outpatients or non-hospital patients. Per 
the above Medicare guidelines, we find the Medicare rule for payment of CPT code 85060 for April 06, 2020, 
has not been met. If the provider determines that a billing error occurred during the initial submission of the 
denied claim, the plan will accept a submission of a corrected claim to consider services for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and when necessary the appropriate Place of 
Service (POS) code. In this case, the claim cannot be paid as billed based on the POS code. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee on April 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 27, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan timeframe in which 
to make a decision expired and the case was forwarded to Maximus. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. The record shows that a claim for this 
service was not filed until May 4, 2020 which is the date the waiver of liability was signed. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee on March 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 3, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says CPT code 70553 denied EX code 34A because the Revenue Code and HCPCS code do 
not match. According to our policy, which is based on the Official UB-04 Data Specifications Manual, certain 
Revenue Codes require an appropriate HCPCS code to be reported on the same line. For CPT code 70553, 
based on the UB editor, the Revenue code is 0611 and 0614 was reported on the claim.  
 
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 claim submitted has errors 
preventing payment. The Plan states a corrected claim would be reviewed if submitted. Therefore, we decided 
that the Plan does not have to pay for physician services provided to the enrollee on February 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional logisticare mileage (A0170). 
 
You asked the Plan to pre-approve additional logisticare mileage. You say that the additional mileage is 
needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. 
Therefore, coverage criteria has not been met. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per calendar year when each one-way trip 
does not exceed 50 miles 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 logisticare mileage (A0170).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional logisticare mileage (A0170). 
 
You asked the Plan to pre-approve additional logisticare mileage. You say that the additional mileage is 
needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. 
Therefore, coverage criteria has not been met. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way transportation trips per calendar year when each one-way trip 
does not exceed 75 miles 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 logisticare mileage (A0170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 17, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you asked the office if they accepted the 
Plan and you were told yes. The Plan denied your request. The Plan says the enrollee must receive care from 
in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an 
in-network provider, which requires prior authorization from the plan. 
 
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 
laboratory services. 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 laboratory services provided on March 17, 2020.