Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric evaluation (90792) provided on October 4, 
2018. 
 
You asked the Plan to pay for a psychiatric evaluation. You say that the enrollee presented incorrect insurance 
information. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a psychiatric evaluation was not filed until February 19, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for a psychiatric evaluation (90792) provided on October 4, 2018.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral drugs provided during an emergency room visit from 
April 10 to April 11, 2020. 
 
You asked the Plan to pay for the oral drugs provided during an emergency room visit. You say that the 
enrollee has dementia and shouldn't have been given drugs. You say that the bill from the hospital does not say 
what drugs were given. The Plan denied your request. The Plan says the items in dispute are not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The records show that there were oral drugs provided in the emergency room, including 
Rocephin and Doxycycline, which are considered self-administered and are not among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for oral drugs provided 
during an emergency room visit from April 10 to April 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 4, 
2020 through January 5, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from January 4, 2020 through January 
5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the sleep study from February 21, 2018 
shows that you had normal testing and there was no established diagnosis of obstructive sleep apnea (OSA). 
The report does not indicate that the CPAP was applied during the study. The records do not support that a 
CPAP is reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have osteoarthritis and you are unable to 
walk. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit (CPT Code G0439) provided on April 
9, 2020. 
 
You asked the Plan to pay for the annual wellness visit. You say that you want to continue to see this provider 
because you are dissatisfied with the services you received from another provider. The Plan denied your 
request. The Plan says you exhausted your benefit for annual wellness visits. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the annual wellness visit have not been met. Review of the file shows that you already had an 
annual exam done on February 28, 2020. Your EOC states that this is covered once every 12 months. 
Therefore, we decided that the Plan does not have to pay for annual wellness visit (CPT Code G0439) provided 
on April 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 6 to 
July 9, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible for costs accrued after critical errors were made during an open heart bypass surgery in May of 
2019. 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 $360 
copayment for each day for days 1 to 5 of an inpatient hospital stay.  
 
You have been asked to pay $1,080, or a $360 copayment for each day for 3 days, for an inpatient hospital stay. 
An inpatient hospital stay falls within the "Inpatient hospital 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 inpatient hospital stay from July 6 to July 9, 2019.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on April 20, 2020. 
 
You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
radiology 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 radiology services provided on April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve power operated vehicle. You say that you cannot use the walker that you 
were approved for and cannot walk long distances. The Plan denied your request. The Plan says the denial of 
authorization for this item is correct, because you use a cane inside and use a scooter for outdoor use. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power operated vehicle. Our reviewer 
says that you do not meet the Medicare criteria for the requested power mobility device. Our physician 
reviewer found the documentation indicates that you have a mobility limitation, but does not support that this 
limitation significantly impairs your ability to participate in one or more mobility-related activities of daily 
living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. 
Furthermore, the consultation by a physical therapist indicates that your mobility limitations can be sufficiently 
and safely resolved by the use of an appropriately fitted walker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power operated vehicle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750). 
 
You asked the Plan to pre-approve the crown. You say that you would like reconsideration because this service 
is medically necessary. The Plan denied your request. The Plan says documentation provided demonstrates 
severe furcation involvement on the molar. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
dental record and radiographs indicate that tooth #19 appears to have a crack extending through the crown and 
mesial root resulting is severe bone loss around the mesial root extending to the bifurcation. Our physician 
reviewer found the prognosis for retention of tooth #19 is poor therefore, placing a crown not the standard of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management service (99495) rendered 
by the out of network (OON) provider on March 3, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the transitional care management service (99495) rendered by the out of network (OON) 
provider on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion procedures and services (99601)  home 
infusion/specialty drug administration, per visit (up to 2 hours) (96602) provided September 24, 2018. 
 
You asked the Plan to pay for the home infusion services. You say that the records should support the necessity 
of the service in dispute. The Plan denied your request. The Plan says invalid procedure code for this service. 
 
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, CPT codes 99601 and 99602 have a status code of "I". Medicare guidance says status code "I" is 
not valid for Medicare purposes. Medicare used another code for reporting of, and payment for, these services. 
You can find this information in the Medicare Claims Processing Manual Chapter 23 - Fee Schedule 
Administration and Coding Requirements, Section 30.2.2. Therefore, we decided that the Plan does not have to 
pay for home infusion procedures and services (99601)  home infusion/specialty drug administration, per visit 
(up to 2 hours) (96602) provided September 24, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration and an inpatient hospital 
admission. 
 
You asked the Plan to pre-approve bone marrow aspiration and inpatient admission. You say that you are 
appealing with records. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because bone marrow aspiration is experimental/investigational and because the approved 
services can be performed at an observation level of care. 
 
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 bone marrow aspiration and inpatient 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental in spinal 
fusion surgery. More research is needed to show the safety and efficacy of bone marrow aspiration. Although 
the bone marrow aspiration remains denied, the Plan approved the remaining requested services at the 
outpatient level of care. The limited spinal fusion surgery may be performed safely with an observational stay 
and does not require inpatient admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration and inpatient admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve bone marrow aspiration and an inpatient hospital 
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the stockings for the 
veins in your legs. The Plan denied your request. The Plan says the compression stockings are examples of 
wound care items which are non-covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve these items an expandable controller (E2377) and 
harness (E2313). 
 
You asked the Plan to pre-approve these items an expandable controller and harness. You say that the enrollee 
needs these items. The Plan denied your request. The Plan says these items are not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically 
necessary for the above listed purposes. 
 
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 an expandable controller and harness. 
Our reviewer says that the requested expandable controller and harness are not medically necessary. Our 
physician reviewer found the documentation does not reveal that the patient requires other types of proportional 
input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc.) The patient does 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and harness have not been met. Therefore, we decided 
that the Plan does not have to pre-approve these items an expandable controller (E2377) and harness (E2313).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Jevtana (Cabazitaxel) and Carboplatin. 
 
You asked the Plan to pre-approve Cabazitaxel and Carboplatin. You say that the combination of Cabazitaxel 
and Carboplatin is supported by literature, and you believe it would be the treatment option that is most likely 
to help the enrollee. The Plan denied your request. The Plan says that there is little evidence to show that the 
combination of drugs would be effective and safe. 
 
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 Cabazitaxel and Carboplatin. Our 
reviewer says that Jevtana (Cabazitaxel) and Carboplatin are medically reasonable and necessary for the 
enrollee. Our physician reviewer found the use of these drugs is supported by the major drug compendia. The 
use is not listed as not indicated, not supported or not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cabazitaxel and Carboplatin have been met. Therefore, we decided that the Plan 
has to pre-approve Jevtana (Cabazitaxel) and Carboplatin.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth 10. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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. The Plan covers these services 
when the services are medically necessary and reasonable.  
 
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 not medically necessary. Our physician reviewer found the submitted dental record and 
radiographs do not clearly show that tooth 10 has significant coronal breakdown. The radiographs and 
photographs are not clear enough to support that the requested crown is reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a crown on tooth 10.