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

 
We decided that the Plan does not have to pre-approve a PET scan (CPT 78815) provided to the enrollee on 
July 24, 2020. 
 
You asked the Plan to pre-approve the scan. You say that this should be paid for. The Plan denied your request. 
The Plan says PET procedures performed to inform the subsequent treatment strategy of cancerous tumors 
(modifier PS) must be reported with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 
scan at issue in this case was not medically reasonable and necessary. Our physician reviewer found CMS rules 
for reimbursement specify that specific diagnosis as to cell type and location of tumor be included in the report 
to qualify for reimbursement.  In this case, the dictated indication is nonspecific lung cancer, site not specified. 
As such CMS criteria for reimbursement 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 the scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a PET scan (CPT 78815) provided to the enrollee on July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 29, 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 periodic oral evaluation, bitewings, and prophylaxis 
provided on August 18, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that the 
providers office contacted the Plan to confirm your benefits, and were given incorrect information. The Plan 
denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that 
this provider's office contacted the Plan on August 18, 2020, were advised that they were OON with your Plan, 
and were also faxed a summary of your benefits which indicated that you do not have coverage for OON 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, bitewings, and prophylaxis provided on August 18, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) provided. 
 
You asked the Plan to pay for the surgical placement of implant body. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says these services 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body (D6010) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on 
September 3, 2020. 
 
You asked the Plan to pay for the incomplete endodontic therapy. You say that you had dental work for a root 
canal started on September 3, 2020, and were then referred to another provider because of complications. You 
also say that you feel the services should be covered because you paid out of pocket, and your paperwork says 
you have no-charge for pre-approved work. The Plan denied your request. The Plan says this service is not 
covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incomplete endodontic therapy (D3332) provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone graft at time of implant placement and two 
endosteal implants provided on March 3, 2020. 
 
You asked the Plan to pay for the bone graft and endosteal implants. You say that you would like these services 
covered at the in-network rates. The Plan denied your request. The Plan says these services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
graft at time of implant placement and two endosteal implants provided on March 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for arthroplasty provided from December 9, 
2019, to December 10, 2019. 
 
You asked the Plan to waive the coinsurance for arthroplasty. You say that you were told that you would only 
owe a $150 copayment and cannot afford the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and a $150 
copayment for all other services. 
 
You received arthroplasty on December 9, 2019, to December 10, 2019, at an outpatient hospital facility. 
Arthroplasty is considered an outpatient surgical procedure. The total allowed amount is $10,593.53 and 20% 
of that is $2,118.70.   
 
You have been asked to pay the total coinsurance amount of $2,118.70 for arthroplasty. Arthroplasty 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 coinsurance for arthroplasty provided 
from December 9, 2019, to December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
head/brain rendered on September 14, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you don't feel the copayment 
should be that high. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment per day, per provider for Medicare-covered diagnostic radiology services.  
 
Review of the file shows that you received a CT scan of the head/brain on September 14, 2020. Per the contract 
with the Plan, there is a $225 copayment per day, per provider for Medicare-covered diagnostic radiology 
services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
However, the Medicare allowed amount for these services was $106.49. Given that the allowed amount was 
less than the $225 copayment, you have been asked to pay $106.49 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) 
scan of the head/brain rendered on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited dental exam to evaluate a problem (D0140) and 
panoramic X-ray (D0330) provided on July 21, 2020. 
 
You asked the Plan to pay for the limited dental exam to evaluate a problem and panoramic X-ray. You say that 
you had not exceeded your Plan benefit on this date of service. The Plan denied your request. The Plan says the 
benefits for these services have been exhausted. 
 
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 limited 
dental exam to evaluate a problem and panoramic X-ray once every year and once every 3 years, respectively. 
 
We looked at the file and Medicare rules. The file indicates that you also had these services performed on 
August 4, 2020. Although this date of service is after July 21, 2020, the Plan actually processed this claim first. 
Therefore, based on the August 4, 2020 date of service, you had exhausted your benefit for the limited dental 
exam to evaluate a problem and panoramic X-ray. Based on this information, we decided that the Plan's rules 
for coverage of the limited dental exam to evaluate a problem and panoramic X-ray have not been met. 
Therefore, we decided that the Plan does not have to pay for the limited dental exam to evaluate a problem 
(D0140) and panoramic X-ray (D0330) provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health visits. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee requires continued home 
health visits for continued teaching and observation. The Plan denied your request. The Plan says that there is 
no documentation that shows a medical problem that needs special care that only a skilled person can do.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health services. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation doesn?t 
support that the member requires skilled nursing services or skilled rehab services to provide treatment that is 
medically necessary. The member does not require skilled nursing or rehab services to effectively provide 
treatment, care, and/or services in order to improve the member?s condition, perform a maintenance program to 
maintain the member?s condition and/or prevent deterioration.  The member has been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET with CT (78815) provided. 
 
You asked the Plan to pay for the PET with CT. You say that you would like reconsideration because this is an 
ancillary provider who was approved by the Plan. The Plan denied your request. The Plan says the diagnosis 
code billed on the claim is not appropriate for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 78815 is not supported in the record. Specifically, Medicare shares a list of appropriate 
diagnosis codes for PET procedures performed to inform the subsequent treatment strategy of cancerous 
tumors. Diagnosis code C83.30 is not listed as appropriate for this service. Based on this information, we 
decided that Medicare rules for coverage of the PET with CT have not been met. Therefore, we decided that the 
Plan does not have to pay for PET with CT (78815) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered from August 12, 2019 to August 16, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate NPI 
number. 
 
We looked at the file and Medicare rules. The claim for these services was not billed with the required NPI and 
taxonomy numbers. 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 services rendered from 
August 12, 2019 to August 16, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) of the neck (72141).

You asked the Plan to pre-approve an MRI of the neck. You say that an MRI 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 reviewed the case file and the reopen request. At issue is coverage for an MRI of the neck. The Maximus Physician Reviewer determined that the enrollee has cervicalgia and a prior CT scan was negative. An MRI was deemed to be necessary to determine the cause of the enrollee's pain. The Plan has requested a reopen stating that the medical records show no documentation of any prior conservative care for the complaint of neck pain. Our Medical Director says the medical records show a diagnosis of cervical disc disorder with radiculopathy in the cervical region. On July 13, 2020 you were evaluated by an otolaryngologist for follow-up of ear pain. At that time, you reported sporadic left-sided neck pain when turning her head to the right. The documentation regarding the neck pain is limited, and there is no documentation of specific treatment for the pain. The neck examination was normal. The report was "Chronic neck pain for years. Prior neck CT scan negative, patient requesting alternative study, neck MRI ordered." Based on the medical records provided, the Plan is correct in this case. The documentation is insufficient to demonstrate that an MRI of the neck was medically reasonable and necessary for the enrollee 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 an MRI of the neck have not been met. Therefore, we decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) of the neck (72141).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and attendant control (E2331, 
E2313, E2377, E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and attendant control. You say that the items are 
medically necessary. The Plan denied your request. The Plan says these features are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. Attendant controls cannot be covered when an enrollee-operated joystick is provided. 
 
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 expandable controller and attendant 
control. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found 
the documentation does not reveal that the patient needs an expandable controller to operate other types of 
input devices. The patient has sufficient strength in the upper extremities to operate any power options through 
their own individual switches. An attendant control is not covered when a standard beneficiary-operated 
joystick is provided. 
 
 
 
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 expandable controller and attendant control have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and attendant control (E2331, 
E2313, E2377, E2311) for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a failure of other radiation treatments, including intensity-
modulated radiation therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are a few studies specifically describing proton therapy for pelvic radiation for prostate cancer. A 
clinically meaningful, plausible benefit from proton therapy was not shown in the case records. Proton therapy 
will generally reduce normal tissue exposure but not always in a clinically meaningful manner. In order to 
establish medical necessity, a plausible clinical benefit should be demonstrated. Also- in the setting of 
metastatic disease, the treatment plan for radiation should follow accepted standards with respect to dose and 
fractionation when potentially justifying the need for proton therapy. The enrollee is prescribed to receive 25 
fractions to a dose of 45-56.25 Gy (with 45 Gy to the pelvis and 56.25 Gy to the lymph nodes) followed by a 
12-fraction boost to the prostate bed to 66..6 Gy total dose to the pelvis. Notably, there is no quantifiable 
dosimetric rationale for the need of proton therapy (i.e. showing that a non-proton based plan would result in 
unacceptable normal tissue exposure). Arguably, there should be some justification of a 37-fraction course of 
pelvic radiotherapy in a patient with metastatic disease, particularly when requesting coverage for proton 
therapy. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on August 10, 2020. 
 
You asked the Plan to pay for an electrocardiogram. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not separately payable from the enrollee's inpatient care. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was inpatient at the time this 
service was provided. Based on this information, we decided that Medicare rules for coverage of an 
electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an 
electrocardiogram (93010) provided on August 10, 2020.