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

 
We decided that the Plan does not have to pay for the medical services provided on October 6, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network with the member's Plan, the services were not 
approved in advance and the services were not urgent or emergent. 
 
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 the medical services provided on October 6, 2020, 
by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pair of therapeutic off-the-shelf depth-inlay shoes with 
3 pairs of custom molded multi-density inserts to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the shoes and inserts from an OON provider. You say that the enrollee 
needs the diabetic shoes and the DME supplier that is in-network is too far away for the enrollee and does not 
provide the needed services. The Plan denied your request. The Plan says there are in-network providers who 
can provide the requested items directly to the enrollee's home. The Plan says that an HMO exception is not 
medically necessary. 
 
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. The Plan supplied the name of an in-
network provider with whom they verified is accepting new patients, provides the option to go to the enrollee's 
home, can service the enrollee in a reasonable amount of time (typically a week), and who can supply the 
specific items being requested.  We found no exception that would require the Plan to pre-approve these the 
requested items from an OON provider. Therefore, we decided that the Plan does not have to pre-approve a 
pair of therapeutic off-the-shelf depth-inlay shoes with 3 pairs of custom molded multi-density inserts 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 pay for the periapical x-rays (D0220) you received on August 25, 
2020. 
 
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 services are not among 
those covered under this benefit. The Plan covers only bitewing x-rays, full-mouth x-rays, and panoramic x-
rays. Periapical x-rays are not covered. Therefore, we decided that the Plan does not have to pay for the 
periapical x-rays (D0220) you received on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye surgery to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve an eye surgery. You say that you would like approval for these services to 
be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers 
available for 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 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 
an eye surgery to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 17, 
2020, through July 16, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost share was applied 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 $370 
copayment each day for days one to five for inpatient hospital care.  
 
You have been asked to pay a $370 copayment each day for days one to five for inpatient hospital care. This 
falls within the inpatient hospital care benefit category. You were in the hospital for twenty-nine days and were 
only asked to pay a copay for five days ($370 x 5 =$1,850). 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 inpatient hospital care provided on June 17, 2020, through July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on February 20, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you should not be charged. The 
Plan denied your request. The Plan says the copayment was applied 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.  
 
Review of the file shows that you received ER services on February 20, 2020. The records confirm that you 
were seen and received services. You have been asked to pay a $90 copayment for these services. These 
services fall 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 the emergency room (ER) services rendered on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), panoramic radiographic image (D0330), extraction, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140 x 6) and non-intravenous conscious sedation (D9248) provided on July 6, 2020, by an 
out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you had dental surgery and it was an extreme 
emergency as you had six (6)  teeth hanging by a thread in your mouth. You state after several calls trying to 
find a dentist in-network, you went to a clinic out-of-network. The Plan denied your request. The Plan says the 
provider is out-of-network and there are services that would not be covered even if rendered by an in-network 
provider. 
 
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 services are not covered when rendered by an out-of-network provider. Furthermore, D9248 would not be 
covered regardless if you used an in-network provider. 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 
comprehensive oral evaluation - new or established patient (D0150), panoramic radiographic image (D0330), 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x 6) and non-intravenous 
conscious sedation (D9248) provided on July 6, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor device (E0651) and segmental 
pneumatic appliance (E0667x2). 
 
You asked the Plan to pre-approve pneumatic compression device and appliance. You say that please reverse 
the denial and authorize coverage for the prescribed pump to treat the enrollee's lymphedema. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare's criteria for medically reasonable and 
necessary. The provider has not given documentation of a completed 4 week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
appliance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, the lymphedema has not been documented to 
be unresponsive to other clinical treatment over the course of a required four-week trial. A four-week trial of 
conservative therapy demonstrating failed response to treatment is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pneumatic compression device and appliance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve pneumatic compressor device (E0651) and segmental 
pneumatic appliance (E0667x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81542, 88381) provided on 
September 24, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this 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 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 the laboratory services (81542, 88381) provided 
on September 24, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
non-surgical management of a hip fracture after a fall. Medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit received on 
August 02, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not feel you 
were treated professionally, therefore you are not liable for the $90 copayment. The Plan denied your request. 
The Plan processed the emergency care copayment of $90 in accordance with the Evidence of Coverage. 
 
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 each Medicare-covered emergency room visit.  
 
You have been asked to pay $90 for each Medicare-covered emergency room visit. This 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 the emergency room 
visit  received August 02, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) orbit, 
face, and/or neck (70543) injection, gadoterate meglumine, 0.1 ml (A9575) magnetic resonance imaging (MRI) 
spinal canal and contents (72148) provided from August 24, 2020, to September 2, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that you were under the 
impression that these copayments would be waived due to the COVID waiver. The Plan denied your request. 
The Plan says these claims were processed and the correct copayment was applied per the Evidence of 
Coverage. 
 
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 $200 
copayment per visit for all other outpatient diagnostic and therapeutic services and supplies such as MRA's, 
MRI's, CT scans, PET scans and hyperbaric oxygen therapy.  
 
You have been asked to pay $400 for the diagnostic services. The diagnostic services fall 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. Therefore, we decided that the Plan does not have to waive the 
copayment for magnetic resonance imaging (MRI) orbit, face, and/or neck (70543) injection, gadoterate 
meglumine, 0.1 ml (A9575) magnetic resonance imaging (MRI) spinal canal and contents (72148) provided 
from August 24, 2020, to September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchoscopy with balloon occlusion, placement of 
tracheal stents, and removal of foreign body. 
 
You asked the Plan to pre-approve bronchoscopy services. You say that the enrollee needs this to breathe 
better. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the enrollee is above the recommended age for this procedure, has not completed a supervised 
pulmonary rehabilitation program in the past 6 months, and her Forced Expiratory Volume (FEV1) is above 
45%. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 bronchoscopy services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has moderate to severe chronic obstructive pulmonary disease (COPD). 
However, the enrollee is 77 years old while the age range for endobronchial valve (EBV) placement is 40 to 75 
years old. The Forced Expiratory Volume (FEV1) should be between 15% to 45% of predicted, but the 
enrollee's results have generally been greater than 45% of predicted. In addition, the enrollee has had frequent 
exacerbations and other complicating factors which could increase risks and/or decrease benefits of this 
procedure. The records do not support or justify placement of tracheal stents or removal of a foreign body. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchoscopy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bronchoscopy with balloon occlusion, placement of tracheal stents, and removal 
of foreign body.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device (CPT Code 22869). 
 
You asked the Plan to pre-approve the device. You say that the service is necessary. The Plan denied your 
request. The Plan says the Vertiflex is investigational and experimental and member is not receiving this device 
as part of a Medicare covered clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex Superion device (CPT Code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve re-treatment of a previous root canal (D3348). 
 
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied 
your request. The Plan says re-treatment of a previous root canal is not listed as a covered service. 
 
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 pre-approve re-
treatment of a previous root canal (D3348).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 26, 2019 to March 
31, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
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 these services was not filed until September 2, 2020. A valid Waiver of 
Liability (WOL) was not received until October 12, 2020. 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 the surgical services rendered on March 26, 2019 to March 31, 2019.