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

We decided that the Plan does not have to pre-approve the Optifast weight loss program product.

You asked the Plan to pre-approve the Optifast weight loss program product. You say that your primary care physician recommended that you participate in the Optifast weight loss product program. The Plan denied your request. The Plan says Optifast is not covered by Medicare and it is not covered by the Plan.

The Plan must follow Medicare rules. Medicare rules say that Medicare pays for MNT services provided by a registered dietitian or nutrition professional when the beneficiary is referred for the service by the treating physician. Medical nutrition therapy services means nutritional diagnostic, therapeutic, and counseling services provided by a registered dietitian or nutrition professional for the purpose of managing diabetes or a renal disease. Medicare rules say that nutritional supplements are non-covered by Medicare. 

We looked at the file and Medicare rules. The Optifast program does not meet the criteria to be considered a medical nutritional program as it is focused on weight loss and not specifically for the management of diabetes or renal disease. This also includes nutritional supplements which are likewise non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the Optifast weight loss program product.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had at an 
outpatient hospital facility on May 22, 2020. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that when you had a different 
insurer, you were never charged cost sharing for ultrasounds following a mammogram. The Plan denied your 
request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed 
amount for the ultrasound is less than your copayment responsibility, you are responsible for the full 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 a $75 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a $75 copayment for the breast ultrasound. This amount applies regardless of the 
reason for the ultrasound. 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 breast ultrasound you 
had at an outpatient hospital facility on May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that this testing enabled the enrollee's treating physician 
to determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because this provider is out-of-network with the Plan and the 
ordering physician is also out-of-network with the Plan. 
 
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 medical services provided on July 22, 2020 by 
an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 physician's services provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that drug testing is covered when specific criteria are
met.
We looked at the file and Medicare rules. There is no documentation to support that the testing meets the
Medicare criteria for coverage. 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 drug testing
rendered on January 21, 2020.
LCD L36029 referenced by the Plan is not relevant where the testing was rendered and was not used in the MAXIMUS determination.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
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 there is no need for daily skilled therapy services to be provided by a 
skilled therapist on a daily basis and there are no daily skilled nursing needs. 
 
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 your condition does not meet 
Medicare criteria for 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 skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient assisted living visit (99336) provided 
on May 28, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient assisted living visit (99336) 
provided on May 28, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DME to be provided by the requested provider. 
 
You asked the Plan to pre-approve the DME. The Plan denied your request. The Plan says you must receive 
care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out 
of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve DME to be 
provided by the requested provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two bone replacement grafts, two surgical placements of 
implant bodies: endosteal implants, four surgical placement of mini implants, two first 15 minute increments of 
intravenous moderate (conscious) sedation/analgesia, and four subsequent 15 minute increments of intravenous 
moderate (conscious) sedation/analgesia. 
 
You asked the Plan to pre-approve the bone replacement grafts, endosteal implants, placement of mini 
implants, and sedation/analgesia services. You say that you need to have your jaw rebuilt because your denture 
does not fit. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental 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 pre-approve two 
bone replacement grafts, two surgical placements of implant bodies: endosteal implants, four surgical 
placement of mini implants, two first 15 minute increments of intravenous moderate (conscious) 
sedation/analgesia, and four subsequent 15 minute increments of intravenous moderate (conscious) 
sedation/analgesia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assisted living stay provided from April 6, 2020, to May 
31, 2020. 
 
You asked the Plan to pay for assisted living. You say that the enrollee was not told that this stay may not be 
covered until after 4 weeks of the stay. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because custodial care is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care, such as assisted living facility 
care, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of assisted living have not been met. Therefore, we decided that the Plan does not have to pay for an 
assisted living stay provided from April 6, 2020, to May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the topical application of fluoride varnish. We decided that the Plan 
does not have to pay for the periapical x-rays.  
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that you went to the dentist 
for a check-up. You say that they did the x-rays wrong the first time so they had to redo them. You say that you 
feel they do this on purpose to make money off you. You also say that you want a new dentist. The Plan says 
 
 
that periapical x-rays are not listed as a covered service. The Plan says fluoride varnish is not listed as a 
covered service either. 
 
We decided that the Plan has to pay for the topical application of fluoride varnish.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms the conditions in which a service is or 
is not covered. Your contract with the Plan does not say in clear and accurate terms that fluoride varnish is not 
a covered service. Therefore, we decided that the Plan has to pay for the topical application of fluoride varnish.  
 
We also decided that the Plan does not have to pay for the periapical x-rays. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, periapical x-rays are not among those 
covered under this benefit. The Evidence of Coverage clearly lists the covered dental services and periapical x-
rays are not listed. Therefore, we decided that the Plan does not have to pay for the periapical x-rays. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (electronic connection, 
expandable controller, harness, backpack holder). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you do not need to operate 3 or more powered seating actuators through the drive control, a  
separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative 
speech device or computer through the chair's drive control), or an attendant control. Your upper extremity 
strength and functional abilities are sufficient for her to control the power options through their own individual 
switches. The backpack holder is a convenience item and not mainly used to serve a medical purpose. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (electronic connection, expandable controller, harness, 
backpack holder).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan of the brain (CPT code 70450) provided on June 
18, 2020. 
 
You asked the Plan to pay for CPT code 70450. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, we have confirmed that code 70450 
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate 
line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the CT scan of the brain (CPT code 
70450) provided on June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the 
enrollee 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this could be done at a lower level of care, or outpatient treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of 
March 15, 2020 forward as this patient was not shown to be a danger to herself or others. The enrollee was not 
showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing 
any threats the safety. 
 
 
 
 
 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient mental health facility for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional Intensity-Modulated Radiation Therapy 
(IMRT) fractions. 
 
You asked the Plan to pre-approve 20 additional IMRT fractions. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that IMRT is clinically indicated (i.e., medical necessity 
criteria will be met) when highly conformal dose planning is required. 
 
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 20 additional IMRT fractions. Our 
reviewer says that the additional services are not medically necessary. Our physician reviewer found an 
additional 20 fractions (in addition to the 25 that were approved) is unfavorable as the treatment (IMRT >20 
fractions) would not be furnished in accordance with accepted standards of care for patients with metastatic 
disease and in the absence of clinical testing to rule out a bone metastases, there is no justification for 45 
fractions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 20 additional IMRT fractions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 20 additional Intensity-Modulated Radiation Therapy (IMRT) fractions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no 
authorization on file for this service. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the respiratory virus by PCR panel provided on May 14, 2020 billed 
with code 87633. 
 
You asked the Plan to pay for the respiratory virus DNA/RNA testing panel. You say that this was medically 
necessary as ordered by the physician and should be reimbursed. The Plan denied your request. The Plan says 
that this is noncovered according to Medicare rules. This means that no payment can be made even if ordered 
by a network provider. 
 
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. 
 
The enrollee was referred for the respiratory virus DNA/RNA testing panel by a contract provider. The file 
does not show that the plan provided notice that the respiratory virus DNA/RNA testing panel would not be 
covered. The Medicare rules cited by the Plan to show non-coverage are not applicable to Medicare Part B in 
the State of Connecticut. Under Medicare rules, this means the respiratory virus DNA/RNA testing panel is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the respiratory virus by 
PCR panel provided on May 14, 2020 billed with code 87633.  
 
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 transcatheter permanent occlusion or embolization procedure 
provided on September 27, 2018. 
 
You asked the Plan to pay for the assistant at surgery services (61624-80). You say that the Plan should pay 
this claim. Plan denied your request. The Plan says this code is not payable. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
61624-80. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This 
means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. 
Based upon this information, we find that Medicare coverage criteria for the transcatheter permanent occlusion 
or embolization procedure have not been met. Therefore, we decided that the Plan does not have to pay for the 
assistant at surgery services provided on September 27, 2018.