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

We decided that the Plan has to pre-approve a COVID-19 test received on May 6, 2020. 
 
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your 
request. The Plan says that this is not covered for asymptomatic individuals to assess health status as required 
by employer/school, etc. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided a Medicare-approved source to show that COVID 
testing should not be covered in this case. Therefore, we decided that the Plan has to pre-approve a COVID-19 
test received on May 6, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64450) provided October 16, 2020. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the CPT code billed is not support by the documentation submitted. 
 
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 64450 is Injection(s), anesthetic agent(s) and/or steroid; 
other peripheral nerve or branch. 
 
We find that CPT code 64450 is not supported in the medical record. Specifically, the documentation provided 
supports the procedure was a genicular nerve block. This procedure is more appropriately reported with CPT 
code 64454. Based on this information, we decided that Medicare rules for coverage of the injections have not 
been met. Therefore, we decided that the Plan does not have to pay for injections (64450) provided October 16, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a power wheelchair with accessories 
provided on July 30, 2020. 
 
You asked the Plan to waive the coinsurance for power wheelchair. You say that you cannot afford this amount 
and would not have purchased this if you had known your out-of-pocket cost would be so high. The Plan 
denied your request. The Plan says the coinsurance amount 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 20% 
coinsurance for power wheelchair with accessories. The allowed amount of this claim is $12,157.06, resulting 
in a coinsurance obligation of $2,431.40. 
 
You have been asked to pay 20% coinsurance for power wheelchair. Power wheelchair falls within the Durable 
Medical Equipment (DME) and Related Supplies 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 a power wheelchair with accessories provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on January 1, 2020, through 
January 31, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says there are no active files for this provider. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly. 
 
Review of the file shows that this claim has been billed without a Medicare provider number. Payment may not 
be made unless the provider is enrolled in the Medicare program. Therefore, we decided that the Plan does not 
have to pay for the outpatient services provided on January 1, 2020, through January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs and you do not require skilled nursing or therapy services on a daily basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Specifically, you do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to change the copayment for the eye exam rendered on October 27, 
2020. 
 
You asked the Plan to change the copayment for these services. You say that you should have a $15 
copayment. 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 $45 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
Review of the file shows that you received an eye exam on October 27, 2020. You have been asked to pay a 
$45 copayment for these services. These services fall within the Medicare-covered outpatient visit for services 
to diagnose and/or treat a disease or condition of the eye 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 change 
the copayment for the eye exam rendered on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
15, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services are not eligible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 15, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a 
participating provider on April 21, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that you do not agree 
with this copayment. You say that all they told you was that your test results were good. The Plan denied your 
request. The Plan says the correct copayment has been 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 $40 
copayment for physician/practitioner services/in-network/provider and professional services/specialist.  
 
You have been asked to pay a $40 copayment for specialist telehealth services. Since a specialist telehealth 
visit was provided, the correct copayment has been applied. Specialist telehealth services fall within the 
physician/practitioner services/in-network/provider and professional services/specialist 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 specialist telehealth services provided by a participating 
provider on April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on August 26, 2020. 
 
You asked the Plan to pay for the dental service. You say that you requested for your records to be sent to this 
dental office. You say that the dentist chose to do his own x-ray to determine the strategy for your care. You 
also say that it appears that most doctors do not take another providers word for the dental need without their 
own examination. The Plan denied your request. The Plan says the periapical x-ray is not listed as a covered 
service. 
 
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 
periapical x-ray (D0220) provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient surgery and laboratory 
services rendered on September 30, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing 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 $175 
copayment for each Medicare-covered outpatient hospital facility visit and a $30 copayment per day, per 
provider for Medicare-covered lab services. 
 
Review of the file shows that you received outpatient surgery at an outpatient hospital on September 30, 2020.  
You have been asked to pay a $175 copayment for these services. These services fall within the Medicare-
covered outpatient hospital facility visit benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan.  
 
The file shows that you received lab services on September 30, 2020. You have been asked to pay a $30 
copayment for these services. These services fall within the Medicare-covered lab services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. 
 
The total amount you have been asked to pay for these services is $205. 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 sharing for the outpatient surgery and laboratory services rendered on September 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a computed tomography (CT) scan 
(74177) and contrast material (Q9967) provided on August 27, 2020. 
 
You asked the Plan to waive the cost-sharing for a CT scan and contrast material. You say that you cannot 
afford these charges. The Plan denied your request. The Plan says these services processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for services including radiological diagnostic 
services and a 20% coinsurance for Medicare-covered Part B drugs. 
 
The CT scan you asked the Plan to waive the cost-sharing for falls within the benefit category of radiological 
diagnostic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible for services including radiological diagnostic services. This cost sharing is a contractual 
obligation that had not been met at the time a CT scan was received on August 27, 2020. You have also been 
asked to pay a $2.40 coinsurance ($12.00 allowed amount x 20% = $2.40). 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 cost-sharing for a computed tomography (CT) scan (74177) and contrast material (Q9967) 
provided on August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. The documentation does not 
support that an additional 25 days of hospitalization are reasonably expected for you in this case. Consequently, 
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided August 13, 2020 
to August 14, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan 
denied your request. The Plan says these drugs are not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) 
provided August 13, 2020 to August 14, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical treatment of hip fracture after a fall. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), the resin based 
composites (D2393) for teeth # 2 and 32,  provided from October 19, 2020, to October 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that the fillings you got should be covered. You also 
say that you did not receive silver fillings, you got the white fillings instead. The Plan denied your request. The 
Plan says the pre-diagnostic test is not listed as a covered service. The Plan also says that multi-surface fillings 
will be processed as a silver filling. The Plan also says that you are responsible up to the contracted fee. 
 
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 pre-diagnostic test is not among 
those covered under this benefit. The Evidence of Coverage clearly states that multi-surface fillings will be 
processed as a silver filling and you will be responsible up to the contracted fee. The record shows that the Plan 
paid for amalgam fillings for teeth # 2 and 32. You are responsible for the difference between the allowed 
amounts. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test 
(D0431), the resin based composites (D2393) for teeth # 2 and 32,  provided from October 19, 2020, to October 
26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing 
or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. 
Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (74150) provided to the enrollee on June 29, 2020.
You asked the Plan to pay for imaging services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states the enrollee had an abdominal CT on June 29, 2020. The submitted documentation supports 1 (one) unit of 74150-26, which was previously paid. There is no additional documentation supporting an additional study which was billed and remains denied. The Plan states that there were no medical records submitted that substantiate the services billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary provide specific records to support the services billed. The Plan provided the claim screens show this service was previously billed. Based on this information, we decided that Medicare rules for coverage of this claim are not met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (74150) provided to the enrollee on June 29, 2020.