Persius/hicric huggingface dataset:
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 the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the patient's functional level requires  an 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Fire 
Department Ambulance on April 14, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that your wife became unconscious at the 
facility to have blood work done and the staff called the ambulance. You say after the medics treated your wife 
her vitals were in normal range. 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 April 14, 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 by Fire Department Ambulance on April 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) provided on April 1, 2020. 
 
You asked the Plan to pay for Positron emission tomography with concurrently acquired computed tomography 
(78815). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the 
diagnosis code on the claim is not an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate ICD-10 code. 
 
We find that ICD-10 code C15.9 is not the appropriate diagnosis code.  Based on this information, we decided 
that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does 
not have to pay for Positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) provided on April 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitors (CGM)
and sensors (K0554, K0553).
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitors (CGM) and sensors (K0554,
K0553). You say that this equipment 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
stating Maximus did not apply the correct LCD criteria.
Our Medical Director looked at the case file and the reopen request and states the Plan is correct in this case.
The Medical records show you have a diagnoses of Type 2 diabetes mellitus without complications. The
records show you have a fear of injections and transfusions. The medical records state that you are not taking
medication for diabetes. In addition, you are refusing to have your blood test taken. Therefore, Medicare
coverage criteria as stated above are not met. 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 continuous glucose monitor and
sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre
continuous glucose monitors (CGM) and sensors (K0554, K0553).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve outpatient endoscopic eustachian tube balloon dilation with 
myringotomy and tympanostomy tube insertion (69436, 69799, 92511). 
 
You asked the Plan to pre-approve outpatient endoscopic eustachian tube balloon dilation with myringotomy 
and tympanostomy tube insertion. You say that the services are necessary. The Plan denied your request. The 
Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve outpatient endoscopic eustachian tube 
balloon dilation with myringotomy and tympanostomy tube insertion. Our reviewer says that the requested 
items/services are considered medically reasonable and necessary in this case. Our physician reviewer found 
the clinical guidelines published by the American Academy of Otolaryngology states that balloon dilation of 
the eustachian tube is appropriate in patients with eustachian tube dysfunction who have failed medical 
therapy. Patients with a middle ear effusion at the time of balloon dilation (as evidenced by type B 
tympanograms) may benefit from concurrent myringotomy with or without tympanostomy tube placement. 
Balloon dilation of the eustachian tube is not considered experimental. There is peer reviewed and evidence 
based publications that clearly state it is a treatment options for patients with eustachian tube dysfunction. Also, 
you meet criteria for a myringotomy with positron emission tomography (PET) placement. You have 
eustachian tube dysfunction (ETD), type B tympanograms, and symptoms from middle ear dysfunction that has 
not improved with medical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient endoscopic eustachian tube balloon dilation with myringotomy and 
tympanostomy tube insertion have been met. Therefore, we decided that the Plan has to pre-approve outpatient 
endoscopic eustachian tube balloon dilation with myringotomy and tympanostomy tube insertion (69436, 
69799, 92511).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the UL, LL, and 
LR quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that the services are necessary due to the 
enrollee's poor hygiene. The Plan denied your request. The Plan says that the documentation submitted does 
not demonstrate evidence of significant bone loss and/or radiographic root-surface calculus on 4 or more teeth 
per quadrant. 
 
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. The Plan covers the scalings 
and planings when the services are medically necessary and reasonable. 
 
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 scalings and planings. Our reviewer 
says that the periodontal scalings and root planings are medically necessary. Our physician reviewer found the 
criteria for coverage for scaling and root planing (D4341) in the upper left, lower left and lower right quadrants 
have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have been met. Therefore, we decided that the Plan 
has to pre-approve periodontal scalings and root planings (D4341) of the UL, LL, and LR quadrants.  
 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer 
compression system to the leg during an occupational therapy visit provided on February 6, 2020 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application. You say 
that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
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 enrollees contract with the Plan says that enrollees must pay a 
$40 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi-layer compression system to the leg during an occupational therapy visit provided on February 6, 
2020 billed with code 29581-GO.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided March 16, 2020 to March 25, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that inpatient coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier Emergency Room and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided March 16, 2020 to March 25, 2020.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for PET imaging; skull base to mid-thigh (CPT Code 78812) to the 
enrollee provided on December 11, 2019. 
 
You asked the Plan to pay for the PET scan. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service is not 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 pay for the PET scan. Our physician reviewer found 
per NCD 220.6.17 for all other solid tumors subsequent treatment strategy is covered. 
 
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 PET scan have not been met. Therefore, we decided that the Plan has to pay 
for PET imaging; skull base to mid-thigh (CPT Code 78812) to the enrollee provided on December 11, 2019.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on December 17, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for robotic surgical techniques (S2900) provided on December 
27, 2019. 
 
You asked the Plan to pay for robotic surgical techniques. You say that this code is supported in the records. 
The Plan denied your request. The Plan says this code is invalid. 
 
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 code S2900 is not supported in the medical record. Specifically, this code has a status 
indicator of. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of robotic surgical techniques have not been met. 
Therefore, we decided that the Plan does not have to pay for robotic surgical techniques (S2900) provided on 
December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on April 21, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on April 21, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lipid testing, complete blood count (CBC) testing, and urinalysis 
provided on January 17, 2020. 
 
You asked the Plan to pay for laboratory tests. You say that these tests are covered for the diagnosis codes 
billed. The Plan denied your request. The Plan says that the denial of payment for these services is correct, 
because these tests are not a Medicare benefit and are done for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain specific tests are covered by 
Medicare for screening purposes. Lipid testing is specifically covered for screening purposes when performed 
for screening for cardiovascular disorders. The Plan must follow Medicare rules. The rules say that Medicare 
health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding 
its decision to deny coverage or payment. 
 
We looked at the file and Medicare rules. The lipid testing billed was performed for screening purposes, 
however it is a test specifically covered by Medicare for this purpose. Additionally, the complete blood count 
(CBC) and urinalysis tests were not ordered for screening purposes but were ordered for a non-routine 
diagnosis. The Plan did not provide any other justification for their denial of payment but denied payment 
exclusively on the basis that these tests are non-covered when performed for screening purposes. Based on this 
information, we decided that Medicare rules for coverage of laboratory tests have been met. Therefore, we 
decided that the Plan has to pay for lipid testing, complete blood count (CBC) testing, and urinalysis provided 
on January 17, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on May 1, 2020. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
you were advised that there was $6,000 available to cover all dental expenses, and you would not pay out of 
pocket for anything. The Plan denied your request. The Plan says you were billed the appropriate copay 
associated with the services provided. 
 
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, you are responsible for a $195 copay 
for both a complete maxillary denture (D5110) and complete mandibular denture (D5120). Therefore, we 
decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on May 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay 
provided from October 7, 2019 to December 2, 2019. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the enrollee's care was not adequate. 
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 $0 
copayment each day for days 1-20 and a $40 copayment each day for days 21-100 of a covered stay during a 
benefit period.  
 
You have been asked to pay $1,440 for days 21-56 of a SNF stay (36 days x $40). A SNF stay falls within the 
Skilled Nursing Facility (SNF) 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 a 
Skilled Nursing Facility (SNF) stay provided from October 7, 2019 to December 2, 2019.