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

 
We decided that the Plan does not have to pre-approve Lumbar Laminectomy. 
 
You asked the Plan to pre-approve Lumbar Laminectomy. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 Lumbar Laminectomy. 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 back pain. The documentation does not support that criteria for 
surgery has been met. There is no recent trial and failure of physical therapy. More conservative measures are 
needed. Therefore, the enrollee does not meet criteria for the requested 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 Lumbar Laminectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Lumbar Laminectomy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MOHS surgery. 
 
You asked the Plan to pre-approve MOHS surgery. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MOHS surgery is only covered for certain 
indications. 
 
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 MOHS surgery. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the squamous cell carcinoma in situ does not require Mohs surgery in this case. You 
do not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of MOHS 
surgery. Therefore, you do not meet criteria for the requested 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 MOHS surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MOHS surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that this is continued care with doctors 
who know you, your case history and who you trust. You are familiar with the doctors that the plan referred 
you to but you feel the doctors you want to see are far superior. The Plan denied your request. The Plan says 
enrollee's must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 
the outpatient office visit (99213) to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 3, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was billed with an invalid bill type. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99310) provided on February 18, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services by an out-of-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 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 nursing facility care (99310) provided on 
February 18, 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 initial intraoral x-ray (D0220), the additional intraoral x-
ray (D0230), and the panoramic x-ray (D0330) provided on June 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that the x-rays were incorrectly denied. You say that 
the x-rays were required for referral for a required extraction. You also also say that the x-rays were medically 
necessary. The Plan denied your request. The Plan says 1 intraoral x-ray is covered per calendar year. The Plan 
says 1 panoramic x-ray is covered every 5 years. The Plan also says the frequency limits for these services have 
been exceeded. 
 
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 and the x-rays are listed as covered, the 
frequency limits have been exceeded. Intraoral x-rays are covered once per calendar year. The record shows 
that this services was previously paid on January 6, 2020. Panoramic x-rays are covered once every 5 years. 
The record shows that this service was previously paid on February 5, 2019. Therefore, we decided that the 
Plan does not have to pay for the initial intraoral x-ray (D0220), the additional intraoral x-ray (D0230), and the 
panoramic x-ray (D0330) provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from April 2, 2020, through 
April 22, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's 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 physician's services provided from April 2, 2020, through 
April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on March 
9, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of 
service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded 80307 and G0482 provided on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 26, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) 
performed on June 2, 2020. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that similar services 
were fully paid for by the Plan on previous occasions. 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 $500 
copayment for surgery services at an outpatient hospital.  
 
You have been asked to pay a $500 copayment for an esophagogastroduodenoscopy. An 
esophagogastroduodenoscopy falls within the "Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers" 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 esophagogastroduodenoscopy (43239) performed on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power scooter provided on October 11, 2019. 
 
You asked the Plan to pay for the power scooter. You say that walking more than 50 feet is impossible without 
an extreme loss of breath. The Plan denied your request. The Plan says that the records did not include a home 
evaluation to ensure the scooter is usable within the confines of your home. 
 
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records provided do not show that your home provides adequate 
access between rooms, maneuvering space, and surfaces for the operation of the POV that was provided. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the power scooter provided on October 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination (X-Ray) of hand (73130), set up 
of X-Ray equipment (Q0092), and transport of portable X-Ray (R0070) provided on February 26, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for X-Ray of hand, Set up of X-Ray equipment and transport of portable X-Ray. 
You say that the services rendered were medically necessary. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered for an out-of-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 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 radiologic examination (X-Ray) of hand 
(73130), set up of X-Ray equipment (Q0092), and transport of portable X-Ray (R0070) provided on February 
26, 2020, 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 stays provided from 
February 7, 2020, to March 2, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stays. You say that you cannot afford these 
bills. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $325 
copayment per day for days 1 to 5 of an in-network inpatient hospital stay.  
 
You have been asked to pay a $1,625 copayment for days 1 to 5 of your inpatient hospital stay from February 
7, 2020, to February 20, 2020, and a $975 copayment for your 3 day inpatient hospital stay from February 28, 
2020, to March 2, 2020. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stays provided from February 7, 2020, to 
March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjustable bed purchased on March 5, 2020. 
 
You asked the Plan to pay for adjustable bed. You say that the enrollee previously had a hospital bed which 
was dangerous, and this bed is necessary for the enrollee. The Plan denied your request. The Plan says the 
denial of payment for this item is correct, because an ordinary bed sold as furniture does not meet the criteria of 
a hospital bed. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for an adjustable bed purchased on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula (B4152) provided on November 14, 2019. 
 
You asked the Plan to pay for enteral formula. You say that this should be covered. The Plan denied your 
request. The Plan says a valid order was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The order in the file 
is date May 13, 2020, which is after the delivery date for the supplies at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for enteral formula (B4152) provided on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital surgery services provided on December 23, 2019. 
 
You asked the Plan to pay for the hospital surgery services. The Plan denied your request. 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. 
 
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 
hospital surgery 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 hospital surgery services provided on December 
23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on 
December 19, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the provider did not treat 
or fix the problem and that a representative of the provider's office told you there was no charge for the service. 
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 consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctors office visits" 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 a specialist office visit (99213) on December 19, 2019.  
 
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. 
 
Your complaint about receiving erroneous or misleading information about cost-sharing from a representative 
of the providers office 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
9, 2020 to April 30, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because the 
claim is per visit. The Plan denied your request. The Plan says the required Q code was not billed on the claim 
for the billed date of service. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim does not include the required Q code. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from April 9, 2020 to April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from 
February 22, 2019, to August 30, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 
being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B prescription drugs.  
 
The enrollee received Medicare Part B drugs from February 2019, to August 30, 2019. Therefore, they are 
responsible to pay their share of the cost-sharing charges. Please see the chart below.  
 
Date of Service Service Total Allowed Amount Amount Owed 
2/22/2019 Medicare Part B drugs $146.91 $29.38 
3/1/2019 Medicare Part B drugs $146.91 $29.38 
3/8/2019 Medicare Part B drugs $146.91 $29.38 
5/9/2019 Medicare Part B drugs $159.38 $31.88 
8/30/2019 Medicare Part B drugs $25.28 $5.05 
 
The total amount the enrollee owes is: $125.07. 

The enrollee has been asked to pay the total coinsurance amount of $125.07 for Medicare Part B drugs. 
Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for Medicare Part B drugs provided from February 22, 2019, to August 
30, 2020.