Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic spinal 
surgeon. 
 
You asked the Plan to pre-approve the referral. You say that your attorney advised you to get care from this 
provider. The Plan denied your request. The Plan says out-of-network care is not a covered benefit. 
 
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 
a referral to an out-of-network orthopedic spinal surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter device (E0445) for the enrollee. 
 
You asked the Plan to pre-approve the oximeter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that oximeters are not covered. 
 
The requested item is statutorily not covered by the plan. Based on this information, we decided that Medicare 
rules for coverage of the oximeter have not been met. Therefore, we decided that the Plan does not have to pre-
approve an oximeter device (E0445) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that you would like approval for these 
services. 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 
durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan does not have to pay forambulance transport provided to the enrolleeon August 3, 2020. You asked the Plan to pay forambulance transport provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met as the enrollee was deceased prior to transport. The Plan must follow Medicare rules. Medicare rules say that code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare uses another code for reporting services provided under these circumstances.Therefore, we decided that the Plan does not have to pay forambulance transport provided to the enrolleeon August 3, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan does not have to pay forambulance transport provided to the enrolleeon August 1, 2020. You asked the Plan to pay forambulance transport provided to theenrollee. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met as the enrollee was deceased prior to transport. The Plan must follow Medicare rules. Medicare rules say that code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare uses another code for reporting services provided under these circumstances.Therefore, we decided that the Plan does not have to pay forambulance transport provided to the enrolleeon August 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on August 22, 2020. 
 
You asked the Plan to pay for hearing aids. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service was obtained through a non-participating hearing provider and was not 
registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a Plan Hearing network provider and registered in advance.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Specifically, you received your hearing aids from a non-
participating provider and did not register the service in advance. This means the hearing aids are not a covered 
service. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 22, 2020.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan does not have to waive or reduce the cost share charged for any of the medical services provided from January 3, 2020, to February 21, 2020.

You asked the Plan to waive or reduce this cost share. You say that you do not believe the cost share charged was correct. The Plan denied your request. The Plan says each cost share was charged based on the service provided and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and clarified their position. The Plan says that Maximus stated the Plan should waive the cost sharing for the Velcade injections. The Plan contract shows that there will be a 20% coinsurance for Medicare Part B Drugs. The Plan says that the records show each claim were billed with code J9041 for Injection,  bortezomib  (Velcade),  0.1  mg,  which both a drug and a medical procedure. The Plan considers this as part of the pharmacy benefit and applied to the coinsurance for Part B drugs. 

The Plan is correct in this case. 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 cost share for each service provided. Upon second review we find 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 cost share charged for any of the medical services provided from January 3, 2020, to February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided 
May 4, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are questioning why you're 
being billed for stitches removed from a surgery in April 2020. You feel that this should be included in the 
original billing of the surgery. The Plan denied your request. The Plan says this claim was 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 $45 
copayment for specialty physician.  
 
You have been asked to pay $45 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's 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 the outpatient office visit (99213) provided May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B injections and specialist visit 
provided on June 17, 2019. 
 
You asked the Plan to waive the cost share for the Part B injections and specialist visit. 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 Part B injections and a specialist visit on the 
date of service at issue in this appeal. The Plan says that the correct cost share 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 15% 
coinsurance for Medicare Part B prescription drugs and a $50 copayment for specialist visits.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B injections 
and a specialist visit on June 17, 2019. You have been asked to pay a 15% coinsurance for the Part B 
injections, totaling $1142.50. The Part B injections fall within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay a $50 copayment for the specialist visit. The specialist visit falls 
within the Physician/Practitioner services benefit category. This means that you have been asked to pay the 
correct amounts 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 cost share 
for the Part B injections and specialist visit provided on June 17, 2019.  
 
Your complaint about not receiving the entire contents of the injection due to an allergic reaction 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: Inpatient Hospital
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 April 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
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 April 24, 2020.
Appeal type: Lab
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 June 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 June 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can safely be received in other settings, for example: a skilled nursing or 
home with home health services. 
 
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 you do not not require the intensity of services provided at an IRF.  Specifically, you 
are not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician 
evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Add Endo Knee-Shin Hydraulic Swing Min Hi 
Active Frame (L5826) and Add Endoskeleton Ak Flexible Protective Outer Surface Cover (L5964). 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that the medical record contains no objective clinical documentation that 
you are at a K3 functional level. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. The treating medical 
practitioner and physical therapy documentation does not support that you are a K3 ambulator and therefore, 
the Add Endo Knee-Shin Hydraulic Swing Min Hi Active Frame (L5826) exceeds your medical needs and is 
not medically reasonable and necessary. The treating medical practitioner documentation does not support that 
you need protection against unusually harsh environmental situations where it is necessary to protect the lower 
limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. Our 
physician reviewer found that your condition does not meet criteria for these items. 
 
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 items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Add Endo Knee-Shin Hydraulic Swing Min Hi Active Frame (L5826) and Add 
Endoskeleton Ak Flexible Protective Outer Surface Cover (L5964).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the you by an out-of-
network provider on August 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
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 you by an out-of-network provider 
on August 7, 2020.
Appeal type: Practitioner Services
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 June 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
You asked the Plan to pre-approve Volara. You say that this device should be considered medically necessary. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
enrollee does not have a covered indication for this device. 
 
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 Volara. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device combines high-frequency chest wall oscillation (HFCWO) and positive airway 
pressure. There is insufficient evidence to support its efficacy in chronic obstructive pulmonary disease 
(COPS). The enrollee does not have a diagnosis for which there is evidence of efficacy of traditional HFCWO 
such as cystic fibrosis, bronchiectasis, or neuromuscular disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Volara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Volara system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on February 24, 2020. 
 
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 procedure code 99291 is not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care spent on the enrollee. 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 pay for 
the critical care services rendered on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose CT scan for lung cancer screening for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there must be at least a 30 pack year history to qualify for this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the records indicate a 
smoking history of 0.6 cigarettes per day for at least 40 years which calculates to 25.2 pack years thus not 
qualifying for this scan. 30 pack years are required per the NCD guidelines. Curiously, the calculation done by 
the referring doctor shows 2 calculations:  0.6 x 40 = 25.2 pack years and then a second entry of 0.3x20 which 
would be an additional 6 pack years. The rationale for the second calculation is not explained by the physician. 
Thus, without further clarification the smoking history does not meet the threshold required per CMS NCD 
guidelines of 30 pack years. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a low dose CT scan for lung cancer screening for the enrollee.