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

 
We decided that the Plan does not have to pre-approve ThyraMIR oncology testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and investigational. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genomic sequence analysis panels are considered to be medically necessary in the treatment of non-small 
cell lung cancer and metastatic colon cancer. No other diagnosis codes support medical necessity for such 
testing. Per the Hayes Knowledge Center Molecular Test Assessment, ?no peer-reviewed articles were 
identified to determine the analytical validity, clinical validity, and clinical utility of the ThyGeNEXT test.? 
The Hayes rating of D2 is based on an ?overall very-low-quality body of evidence.? 
 
 
 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ThyraMIR oncology testing for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat cardiac catheterization procedure. 
 
You asked the Plan to pre-approve the cardiac catherization procedure. You say that it is felt that another stent 
should be placed. The Plan denied your request. The Plan says the enrollee has no symptoms which would 
warrant this treatment. 
 
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 cardiac catheterization procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a male with a history of diabetes, stroke, and coronary 
artery disease, including prior stenting. Based on the records the patient has known coronary disease but no 
documented recent cardiac symptoms, abnormal cardiac exam findings, ischemic ECG changes or provokable 
ischemia on stress testing. In this circumstance the documentation does not support the medical necessity for 
cardiac catheterization. 
 
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 cardiac catheterization procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a repeat cardiac catheterization procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health skilled nursing services provided on June 9, 
2020 billed with code G0299. 
 
You asked the Plan to pay for the home health visit. You say that you are a professional provider and must bill 
on a CMS-1500 form. The Plan denied your request. The Plan says home health services must be billed on an 
institutional claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must bill for home health 
services on an institutional claim. 
 
Code G0299 is a home health code which is only payable to a home health agency and must be billed on an 
institutional claim. Therefore, we decided that the Plan does not have to pay for the home health skilled nursing 
services provided on June 9, 2020 billed with code G0299.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer Superion interspinous 
spacer (CPT Code 22869) and (22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Superion interspinous spacer Superion interspinous spacer (CPT Code 22869) and 
(22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed for the services provided on 
April 15, 2020. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the medical 
record does not show the enrollee received inpatient hospital care. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
We find that inpatient services are not supported in the medical record. The records do not support that 
inpatient care was provided. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services billed for the 
services provided on April 15, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
March 29, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received emergency room services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $120 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on March 29, 2020. You have been asked to pay a $120 copayment for the emergency room services. 
The emergency room services fall within the Emergency care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the emergency room services provided on March 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 1, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Current Procedural Terminology (CPT) code 64486 59 (1 unit) remains not supported. 
The documentation submitted did not include documentation indicating that transversus abdominis plane 
(TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) was performed; therefore, 
the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for 
additional information. 
 
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 records provided do not support 
the codes billed. The Plan states additional information would be reviewed if submitted. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. The Plan denied 
your request. The Plan says the certification dated November 10, 2020 documented the enrollee has none of the 
qualifying diagnoses, does not require intense care coordination and has no high risk for hospitalizations or 
high risk for adverse health outcomes. 
 
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and 
medically complex chronic conditions that are life-threatening or significantly limit your health or general 
functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and 
must require intensive care coordination.  
 
We looked at the file and the Plan?s rules. The file shows that the medical conditions you have stated are not 
eligible medical conditions under the Plan?s benefit. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that this doctor relied on the facility to get 
authorization for these services.  You say these services should be paid because they were medically necessary 
and provided in good faith. The Plan denied your request. The Plan says these services were provided by a non-
Plan provider in a non-Plan facility.  Neither the facility nor the provider of service requested authorization for 
these services. The Plan says that unauthorized, non-plan services are not covered. 
 
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 
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 August 12, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thoracic/lumbar/sacral orthosis (HCPCS L0457) provided 
to the enrollee. 
 
You asked the Plan to pay for the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no face to face encounter with the physician. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the enrollee meets the 
criteria for this brace. No medical records were provided documenting a face-to-face examination (or tele-
health visit) with the enrollee justifying need for the orthosis. 
 
 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a thoracic/lumbar/sacral orthosis (HCPCS L0457) provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 22, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that You did not provide an argument for coverage in 
your appeal request. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could 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 lab services provided on July 22, 2020, by an out-of-network 
(OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on March 22, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says they are the enrollee's secondary 
insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
emergency room services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the emergency room services provided on March 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a CT scan of the thorax (71260) performed 
on September 22, 2020. 
 
You asked the Plan to waive the deductible for a CT scan of the thorax. You say that you should not be billed 
as you were approved for this service. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 each advanced imaging service.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests 
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible for each advanced imaging service. This cost sharing is 
a contractual obligation that had not been met at the time a CT scan of the thorax was received on September 
22, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a CT scan of the thorax 
(71260) performed on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services with CPT code 01620 provided on 
November 30, 2019. 
 
You asked the Plan to pay for CPT code 01620. 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 anesthesia services with the appropriate modifier. 
 
We find that CPT code 01620 is not supported in the medical record. Specifically, in order for anesthesia 
services to be paid, the CPT code must be billed with the appropriate modifier. Based on this information, we 
decided that Medicare rules for coverage of CPT code 01620 have not been met. Therefore, we decided that the 
Plan does not have to pay for the anesthesia services with CPT code 01620 provided on November 30, 2019.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hyaluronic acid injections provided from February 19, 2020, 
to April 30, 2020 out of network. 
 
You asked the Plan to pay for injections provided out of network. You stated in your appeal and in a letter 
directly to this office that you would like the injections reimbursed to you as these injections were medically 
necessary and the Plan should have approved them. The Plan denied your request. There was a pre-service 
appeal for this treatment which was denied by the Plan because your plan contract orthopedist recommended 
new course of cortisone injections. For this retrospective appeal for payment the Plan has denied coverage 
stating you obtained these injections out of network without prior authorization after they had been denied in 
network.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary. The rules also say that Plans can require enrollees to use 
in network providers and can require enrollees to get prior authorization.  
 
When Maximus reviewed the pre-service appeal, our physician reviewer found that Hyaluronic acid injections 
were not medically necessary. Our physician reviewer found the treating plan provider had recommended 
continuation of the corticosteroid injections or advised surgery. We upheld the Plans denial for coverage.  
 
In this retrospective appeal, the Plan has denied coverage for the injections because they were provided out of 
network and without prior authorization. The Plan contract says that enrollee must use Plan providers and work 
within the referral system. The Plan had previously denied this treatment based on the Medicare treatment 
guidelines and the recommendations of your physician. You chose to have this treatment out of network 
without approval. Therefore, we decided that the Plan does not have to pay for  Hyaluronic acid injections 
provided from February 19, 2020, to April 30, 2020 out of network.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided.

You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says no authorization has been obtained.

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 outpatient hospital 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 outpatient hospital services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fora specialist visit and an X-ray provided on July 2, 2020.You asked the Plan to waive the copayments fora specialist visit and an X-ray. You say that you do not understand why the X-ray was necessary because you brought MRI resultswith you.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 ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $35 copayment for X-rays.The medical records show that you had a specialist visit on July 2, 2020. Therefore, you are responsible to pay the $45 copayment. The medical records show that you had an X-ray on July 2, 2020. Therefore, you are responsible to pay the allowed amount of $31.32, which is lessthan the $35 copayment. The total amount you owe is: $76.32. You have been asked to pay the total amount of $76.32 for a specialist visit and an X-ray. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An X-ray falls 
within the outpatient diagnostic tests and therapeutic services and 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 copayments fora specialist visit and an X-ray provided on July 2, 2020.