Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from June 20, 2020, to 
June 22, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the services provided were unauthorized post-
stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for the inpatient hospital care. Our reviewer 
says that the inpatient hospital care was unauthorized post-stabilization care and was not medically necessary 
or reasonable. Our physician reviewer found all inpatient care provided after 10:00 am on June 21, 2020, 
through transfer on June 22, 2020, was not needed on an emergent basis. The enrollee was hemodynamically 
and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility. The 
review has determined that the treating physician did not document (in the physician notes, on a form, or in an 
order) that the patient was not stable for transfer on any dates of service. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from June 20, 2020, to June 22, 2020, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational procedure because of the wide 
variation in efficacy reported in the peer-reviewed literature. Therefore, the request is deemed not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (64625).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 8, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vehicle handicap modifications provided on July 2, 2020. 
 
You asked the Plan to pay for the vehicle handicap modifications. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The vehicle handicap modifications at issue in this appeal do not serve a purpose that is primarily medical in 
nature. Medicare will not pay for equipment used for a patient's comfort or for the convenience of a person 
caring for the patient. Therefore, we decided that the Plan does not have to pay for the vehicle handicap 
modifications provided on July 2, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI with computer-aided detection (CAD) (77049). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee was diagnosed with malignant right 
breast cancer 10/14/2019. She underwent treatment and is now due for follow up. She needs MRI instead of 
mammograms due to severe pain conditions and anxiety. The Plan denied your request. The Plan says that the 
documentation provided does not support that this care is needed to treat your condition and does not meet the 
coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a history of micro-invasive ductal breast cancer. MRI surveillance wanted. Per Am J 
Roentgenology 196(3) supp 2011 pages WS 1-14, indications are 1. screening for women at high risk of 
disease. As the enrollee has had breast cancer I deem her high risk and approve. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI with computer-aided detection (CAD) (77049).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on July 30, 2020. 
 
You asked the Plan to pay for the paramedic intercept services. You say that the Plan should pay this claim 
because you are on a limited income and there was a legitimate need for the service. 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 pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the paramedic intercept provider does not have a contract with the volunteer 
ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to 
pay for the paramedic intercept services provided on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optune Lua electrical stimulation device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not have a diagnosis of glioblastoma multiforme. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of tumor treatment field therapy for any 
indications other than newly diagnosed glioblastoma multiforme will be denied as not reasonable and 
necessary.  
 
We looked at the file and Medicare rules. The file indicates that the Optune Lua is not being requested for the 
treatment of newly diagnosed glioblastoma multiforme. Therefore, we decided that the Plan does not have to 
pre-approve an Optune Lua electrical stimulation device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 1, 2019, to January 31, 2019. 
 
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 billed services do not match the letter of agreement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the denied services are not supported in the medical record. Specifically, the billed services do not 
match the letter of agreement. The letter of agreement is for revenue code 190, and the billed services are for 
revenue code 199. 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 skilled nursing facility (SNF) 
services provided to the enrollee from January 1, 2019, to January 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty with extractions with dental code D7311 
provided on August 31, 2020. 
 
You asked the Plan to pay for dental code D7311. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the dental services with dental code D7311 is 
not covered under your supplemental dental 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 alveoloplasty with extractions with 
dental code D7311 is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for alveoloplasty with extractions with dental code D7311 provided on August 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0429, A0425) 
provided May 13, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be 
waived. 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 $200 
copayment for Ambulance Services.  
 
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport 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 
an ambulance transport (A0429, A0425) provided May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Coude tip urinary catheter provided on April 7, 2020. 
 
You asked the Plan to pay for the Coude tip urinary catheter. The Plan denied your request. The Plan says prior 
authorization is required. 
 
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 
Coude tip urinary catheter. We found no exception that would require the Plan to pay for this item. Therefore, 
we decided that the Plan does not have to pay for a Coude tip urinary catheter provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 18, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior 
authorization was not obtained as required. 
 
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 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 on September 18, 2020 by an out of network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an abscess drainage (10061) provided February 16, 2020. 
 
You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records provided 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 code 10061 is incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple. 
 
We find that CPT code 10061 is not supported in the medical record. Specifically, insufficient documentation 
was provided to support the procedure. The plan requested additional records and none were received. Based 
on this information, we decided that Medicare rules for coverage of the procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for an abscess drainage (10061) provided February 
16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital observation services 
provided from August 6, 2020 to August 8, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital observation services. You say that you 
feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says you received outpatient hospital observation services on 
the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per your 
contract with the Plan. 
 
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 $200 
copayment for Outpatient hospital observation services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient 
hospital observation services from August 6, 2020 to August 8, 2020. You have been asked to pay a $200 
copayment for the outpatient hospital observation services. The outpatient hospital observation services fall 
within the Outpatient hospital observation 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 outpatient hospital observation services provided from August 6, 2020 to August 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on August 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON x-ray services. You say that you were sent to have this x-ray by your 
doctor so you feel it should be covered. The Plan denied your request. The Plan says you received this service 
at an OON facility after an order from an OON provider. This was not urgent/emergent, and there were 
network providers available. 
 
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 chest x-ray provided on August 25, 2020 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 endodontic therapy with dental code D3310 and cone 
beam computed tomography with dental code D0367 provided on July 21, 2020. 
 
You asked the Plan to pay for dental codes D3310 and D0367. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D3310 and 
D0367 are not covered under your supplemental dental 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 endodontic therapy with dental 
code D3310 and the cone beam computed tomography with dental code D0367 are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy with 
dental code D3310 and cone beam computed tomography with dental code D0367 provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits (99213, 95909, 99204) 
provided February 20, 2020, to September 4, 2020. 
 
You asked the Plan to waive the copayments for the specialist visits. You say that the copayments should be 
waived. 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 $50 
copayment for diagnostic tests and specialist visits.  
 
You have been asked to pay a $150 copayment for a diagnostic test and two specialist visits. 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 copayments for specialist visits (99213, 95909, 99204) provided February 20, 2020, 
to September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of low back pain has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure remains experimental. More research is needed to show safety and efficacy for the treatment of low 
back pain. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan does not have to pre-approve a prostate ultrasound (76873).

You asked the Plan to pre-approve a prostate ultrasound (76873). You say that this imaging is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for ultrasound of the prostate. The Maximus Physician Reviewer determined that the requested transrectal prostate ultrasound could be beneficial. The Plan is requesting a reopen stating that you did not meet medically necessary criteria as evidenced by a benign prostate exam and a normal PSA.

Our Medical Director says that the medical records show you have urinary frequency. The prostate exam was unremarkable. The PSA was in the normal range. You were diagnosed with BPH associated with nocturia. The records show you did not want to take prescription medication for urinary frequency. Saw palmetto and diazepam were advised. It is noted that your physician did not feel a prostate ultrasound was necessary. It is documented that you wanted this test to be sure it was not cancer. Our Medical Director states the Plan is correct in this case. The documentation in the case file does not support that a prostate ultrasound was medically reasonable and necessary 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 a prostate ultrasound (76873) have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostate ultrasound (76873).