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

 
We decided that the Plan has to pre-approve ThyGeNEXT and ThyraMIR panels. 
 
You asked the Plan to pre-approve these services. You say that something is wrong inside your throat. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have 
thyroid nodules, as shown on an ultrasound. You have a clinical history of difficulty swallowing (dysphagia).  
A fine needle aspiration was non-diagnostic. Given the size of the nodules, presence of symptoms, and lack of 
diagnostic results from the fine needle aspiration, the requested genetic testing panels are reasonable and 
medically necessary. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve ThyGeNEXT and ThyraMIR panels.  
 
The Local Coverage Determinations (LCDs) referenced by the Plan are not for the state of New Jersey where 
the requested single source testing is performed and were not used in the MAXIMUS determination. 
 
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: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) thorax (71250) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the CT scan. You say that the records should support the necessity of the 
service in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT) thorax (71250) to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that you would like services at an out of 
network facility. 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
medical services to be provided by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee requires are custodial. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF services. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care services provided from 
May 14, 2020, to June 11, 2020. 
 
You asked the Plan to waive the copayment for the wound care services. You say that this was not surgery so 
there should be no copayments. The Plan denied your request. The Plan says you were charged the copayments 
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 $335 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $335 copayment for each of the wound care services. The wound care services 
fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities. 
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 wound care services 
provided from May 14, 2020, to June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper complete denture (D5110). 
 
You asked the Plan to pre-approve an upper complete denture. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says you have exhausted the 
allowable frequency of this 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.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this dental item have not been met. Specifically, a complete denture is covered once every sixty 
months. The record shows that a complete upper denture was previously provided to you on July 28, 2020. 
Your request to receive this item exceeds the allowable frequency within the stated sixty month timeframe. 
Therefore, we decided that the Plan does not have to pre-approve an upper complete denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual 
policy. 
 
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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper partial 
denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need wound care and rehab. The Plan denied 
your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on November 24, 2020 for a right below knee amputation. You are able to ambulate 
with assistance and need assistance with activities of daily living. The complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight 
only in an IRF. You may benefit from multiple therapies but do not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical service provided on October 29, 2019. 
 
You asked the Plan to pay for the hip treatment (27265). You say that you do not owe this bill. The Plan denied 
your request. The Plan says the provider must submit a corrected claim for further processing. 
 
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 27265 is the closed treatment of post hip arthroplasty 
dislocation; without anesthesia. 
 
We find that the claim for CPT code 27265 was submitted incorrectly. The provider is non-contracted and 
therefore the Plan cannot change the claim. Based on this information, we decided that Medicare rules for 
coverage of the hip treatment (27265) have not been met. Therefore, we decided that the Plan does not have to 
pay for the medical service provided on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for an LTACH admission. 
 
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 based on the documentation provided the Plan's denial of LTACH coverage should 
be upheld. The enrollee is currently undergoing treatment at an ACH for a diffuse hemorrhagic stroke in the 
setting of extreme hypertension. The enrollee underwent several neurosurgical procedures and was 
perioperatively intubated/ventilated. Due to aspiration and poor airway protection, it appears that a tracheotomy 
was recommended.  Full ventilator liberation and/or decannulation appear unlikely.  As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the 
LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a nuclear bone scan and CT scan of the left foot 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 that the records show that the same or similar test may have already been done. 
 
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 considered medically reasonable and necessary in this case. Our physician reviewer found in 
the letter of appeal, the clinician who is planning for another surgery for the enrollee plans on using the CT for 
operative planning purposes. The clinician states that the prior MRI did not address all the issues needed for 
pre-op planning. There indeed are cases when CT has anatomic increased resolution for cortical bone and thus 
should be approved. Since there has been questions of infection in the past the requested bone scan should be 
approved and 3 phase bone scan would be of use. This would allow the analysis of blood flow and blood pool 
characteristics as well as the delayed phase which is also needed. The blood flow and pool portions are very 
useful when looking for inflammation or infection and would prove valuable in this patient. Thus both the CT 
of the left foot and the 3 phase bone scan of the feet should be approved for operative planning purposes. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
a nuclear bone scan and CT scan of the left foot for the enrollee.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging provided on February 22, 2020 by an OON provider. 
 
You asked the Plan to pay for the PET with concurrently acquired CT. You say that the referring physician 
orders only the services that are needed in order to render an accurate diagnosis on behalf of the enrollee. The 
Plan denied your request. The Plan says the services were rendered by a non-network provider who does not 
work with the enrollee's health plan. The Plan also says the enrollee was referred by another non-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the PET with concurrently acquired CT for 
attenuation correction and anatomical localization imaging provided on February 22, 2020 by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for a refractive eye exam (92015) performed on June 18, 
2020. 
 
You asked the Plan to hold you harmless for a refractive eye exam. You say that you received this service 
without knowing that your insurance would not cover it. The Plan denied your request. The Plan says that rules 
for payment have not been met. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You received a refractive eye exam from a contract provider. The Plan states that the refractive eye exam was a 
medical exam rather than routine vision care. However, the case record does not contain documentation to 
support the Plan's distinction between a medical and a routine exam. Additionally, the record does not show 
that the Plan provided notice that a refractive eye exam would not be covered. Under Medicare rules, this 
means a refractive eye exam is considered approved by the Plan. Therefore, we decided that the Plan has to 
hold you harmless for a refractive eye exam (92015) performed on June 18, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tangential biopsy of skin (e.g. shave, scoop, cauterize, 
curette); each separate/additional lesion (CPT Code 11103) provided on January 9, 2020. 
 
You asked the Plan to pay for the services. You say that you would like the medical records to be reviewed 
showing that CPT 11103 was down twice. You state you would like the claim to be reprocessed and paid The 
Plan denied your request. The Plan says after the review they found a duplicate claim number for date of 
service January 9, 2020, in the member's history which is paid, and it is an exact duplicate to the appealing 
claim. The Plan stated the claim was denied correctly on the basis of diagnosis, modifier, provider tax ID, date 
of service, patient name, units, billing provider address. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. This 
claim is a duplicate claim in the member's history which is paid, and it is an exact duplicate to the appealing 
claim. The claim was denied correctly on the basis of diagnosis, modifier, provider tax ID, date of service, 
patient name, units, billing provider address. Therefore, we decided that the Plan does not have to pay for 
tangential biopsy of skin (e.g. shave, scoop, cauterize, curette); each separate/additional lesion (CPT Code 
11103) provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on May 13, 2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you had a telehealth visit; you 
never went to the office. You say that you were under the impression that telehealth copayments were being 
waived. The Plan denied your request. The Plan says the copayment 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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay a $35 copayment for the specialist visit. The specialist 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 specialist visit provided on May 13, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Heparin Flush services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
drug requires treatment with highly emetogenic chemotherapy or moderately emetogenic chemotherapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 requested services. Our physician 
reviewer found that heparin lock flush solution is a standard of care and FDA approved for maintaining patency 
of IV devices. The requested use is not listed as not indicated, not supported or not recommended in any of the 
compendia. The documentation supports that the requested drug is safe and effective and otherwise reasonable 
and necessary for this enrollee. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve Heparin Flush services.  
 
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.