Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on May 15, 2020. 
 
You asked the Plan to pay for the provided monitor. The Plan denied your request. The Plan says the enrollee 
only uses insulin once daily. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under 
certain medical conditions. 
 
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 provided monitor. Our physician 
reviewer found that the enrollee has a history of diabetes treated with insulin. Per the documentation she 
receives one insulin injection per day. The records do not show that the enrollee is insulin-treated 3 or more 
times a day, or performs testing 4 or more times a day. Based on the rules and records provided the provided 
CGM  was not medically reasonable or necessary to treat the 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 provided monitor have not been met. Therefore, we decided that the Plan 
does not have to pay for the continuous glucose monitor provided on May 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
November 13, 2019. 
 
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 the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any 
type (CPT Code E2300). 
 
You asked the Plan to pre-approve the item. You say that a typical power chair is not sufficient and a rising 
chair would assist you with getting in and out of bed. The Plan denied your request. The Plan says this item is 
not covered because it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any type 
(CPT Code E2300).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe nuclear test study.You asked the Plan to pre-approvethe nuclear test study. You say that you would like reconsideration because the member is unable to walk on the treadmill.The Plan denied your request. The Plan says the member does not have any symptoms.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 nuclear test study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage criteria are not met since there are no documented covered indications for the procedure. The member does not have symptoms suggestive of coronary ischemia, documented cardiac physical exam abnormalities or documented electrocardiogram. Screening stress testing, even in highrisk patients, has not been shown to improve cardiac outcome.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 nuclear test study have not been met.Therefore, we decided that the Plan does not have to pre-approvethe nuclear test study.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation rendered on October 2, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. The file shows that procedure code 85060 has a PC/TC indicator of 8 
and was billed with POS code 22 for an outpatient hospital. This code is only payable at the inpatient level. 
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 blood smear interpretation rendered on 
October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for post-cataract laser surgery and other ophthalmologyservices providedon June 3, 2019.You asked the Plan to pay for the post-cataract laser surgery and other ophthalmology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 servicesat issue. 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 post-cataract laser surgery and other ophthalmology servicesprovidedon June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral solution, 74 to 100 grams of protein (B4197) and 
parenteral solution, not otherwise specified, 10 grams lipids (B4185) provided December 10, 2019 to 
December 11, 2019. 
 
You asked the Plan to pay for the parenteral solution. You say that please see the attached medical records for 
review and reconsideration of payment of the services rendered. The Plan denied your request. The Plan says 
there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met. 
Multiple attempts were made to the provider for additional information but none was received 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
 
 
We find that 2 units for CPT code B4197 and 20 units for CPT code B4185 are not supported in the medical 
record. The record shows that the Plan made several attempts to obtain the necessary documentation from the 
provider without success. Based on this information, we decided that Medicare rules for coverage of the 
parenteral solution have not been met. Therefore, we decided that the Plan does not have to pay for parenteral 
solution, 74 to 100 grams of protein (B4197) and parenteral solution, not otherwise specified, 10 grams lipids 
(B4185) provided December 10, 2019 to December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on 
December 24, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the copayment should be 
$0. The Plan denied your request. The Plan says the correct copayment was 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 $45 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office 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 a specialist office visit (99213) on December 24, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) on May 
16, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the emergency room 
medical staff could not help you. The Plan denied your request. The Plan says the correct copayment was 
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 $50 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $50 copayment for an emergency room visit. An emergency room visit falls 
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 an 
emergency room visit (99283) on May 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care provided from 
May 26, 2020, to May 28, 2020. 
 
You asked the Plan to waive the copayment for inpatient mental health care. You say that you disagree with the 
charges because of the care you received. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $318 
copayment for days 1-5 for inpatient mental health care.  
 
You received inpatient mental health care from May 26, 2020, to May 28, 2020. Therefore, you are responsible 
to pay a $318 for days 1-2 (May 26, 2020, to May 27, 2020). $318 (copayment) x 2 (inpatient mental health 
days) = $636.  
 
You have been asked to pay the total copayment amount of $636 for inpatient mental health care. Inpatient 
mental health care falls within the inpatient mental health 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 inpatient mental health care provided from May 26, 2020, to May 28, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required, tooth 
#18 and #19 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any 
pins when required, tooth #18 and #19 (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET imaging (7881) provided on March 27, 2020. 
 
You asked the Plan to pay for the PET imaging. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says PET procedures performed to inform the 
subsequent treatment strategy of cancerous tumors must be reported with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 78815 is not supported in the record. Specifically, PET procedures performed to inform 
the subsequent treatment strategy of cancerous tumors must be reported with an appropriate diagnosis. Per the 
Medicare Claims Processing Manual, diagnosis code C34.91 is not included on the list of appropriate codes for 
PET procedures to inform the subsequent treatment strategy of cancerous tumors. Based on this information, 
we decided that Medicare rules for coverage of the PET imaging have not been met. Therefore, we decided that 
the Plan does not have to pay for PET imaging (7881) provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services provided 
from November 22, 2019, to November 27, 2019. 
 
You asked the Plan to waive the copayments for cardiac rehabilitation services. You say that you were not 
informed that you would owe a $25 copayment per each visit. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for cardiac rehabilitation services.  
 
You received cardiac rehabilitation services on November 22, 2019, to November 27, 2019 for a total of 3 
services. Therefore, you are responsible to pay a $25 copayment per each visit. The total amount you owe is: 
$75.  
 
You have been asked to pay the total copayment amount of $75 for cardiac rehabilitation services. Cardiac 
rehabilitation services fall within the cardiac rehabilitation services 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 for cardiac rehabilitation services provided from November 22, 2019, to November 
27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final 
restoration), tooth #8 (D3310). 
 
You asked the Plan to pre-approve the dental services. You say that one of the teeth is getting loose and you 
feel if you do not get the procedure done you could lose the teeth. The Plan denied your request. The Plan says 
the service is not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The health plan contract says that endodontic therapy is not covered. 
Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding 
final restoration), tooth #8 (D3310).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 12, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from an out-of-network provider 
will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our 
network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, 
must obtain authorization from the plan prior to seeking care. 
 
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 
laboratory 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 laboratory services provided on May 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by Springville Ambulance 
Service from October 1, 2019, through October 21, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in your home by the 
medics. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 1, 2019 to October 21, 2019. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services 
provided by Springville Ambulance Service from October 1, 2019, through October 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT 
Code 74177). 
 
You asked the Plan to pre-approve the CT scan. You say that a growth was found behind your stomach in 
2018, and the doctor advised you that you should have is scanned again in the following year. The Plan denied 
your request. The Plan says based on the review of the medical records there is no clinical information 
documenting medical necessity or that meets medical necessity criteria. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the CT scan have not been met. The rules say that all providers are 
required to furnish necessary information to the health plan when requested. Therefore, we decided that the 
Plan does not have to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT Code 74177).
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. The Plan denied your request. The Plan says you do  not require 
close medical monitoring, or intensive therapy services. 
 
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 physician reviewer found 
that you are medically stable after a stroke, with mild expressive aphasia function. The documentation does not 
support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary 
approach to rehab care. You are walking with contact guard to minimal assist using no devices. You need 
physical, occupational, and speech therapy, but not in an IRF. Therefore, an IRF admission is not 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve walker, folding, wheeled, adjustable or fixed height 
(CPT Code E0143) and seat attachment, walker (CPT Code E0156). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says your weight does not meet LCD L33791 criteria for coverage of a bariatric walker. The 
Plan states you would be eligible for a regular walker with a seat based on your weight. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Your weight does not meet LCD 
L33791 criteria for coverage of a bariatric walker. Therefore, we decided that the Plan does not have to pre-
approve walker, folding, wheeled, adjustable or fixed height (CPT Code E0143) and seat attachment, walker 
(CPT Code E0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 cleanliness precautions provided on May 12, 
2020. 
 
You asked the Plan to pay for the COVID-19 cleanliness precautions. You say that you do not feel that you 
should owe the amount because you were unaware that your medical coverage had ended. The Plan denied 
your request. The Plan says this service is not covered. 
 
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 
COVID-19 cleanliness precautions provided on May 12, 2020.