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

 
We decided that the Plan does not have to reimburse you for the smoking hypnosis session provided on 
September 25, 2020. 
 
You asked the Plan to reimburse you for the smoking hypnosis session. You say that you would like to be 
reconsidered for payment on this claim. The Plan denied your request. The Plan says smoking hypnosis is not a 
covered benefit. 
 
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. Neither Medicare nor the Plan cover smoking hypnosis. Therefore, 
we decided that the Plan does not have to reimburse you for the smoking hypnosis session provided on 
September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 had network providers 
available who could have provided 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 lab work provided by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
genicular nerve blocks for treatment of chronic knee pain are experimental. 
 
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 requested services. Our physician 
reviewer found that the enrollee has left knee osteoarthritis. He has tried NSAIDs and has had a home exercise 
program. He has been scheduled for a left total knee arthroplasty. The requested service is considered an 
experimental/investigational procedure.  Therefore, the request is considered not medically reasonable or 
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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve neuroablation services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart 
failure. Medicare coverage criteria are not met since the device should still be considered experimental or 
investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Methylprednisolone injection (J1030), 
Euflexxa injection (J7323), and Vitamin B12 injection (J3420) provided from June 23, 2020, to August 27, 
2020. 
 
You asked the Plan to waive the coinsurance for the Methylprednisolone, Euflexxa, and Vitamin B12. You say 
that you were under the impression these drugs would be fully covered. The Plan denied your request. The Plan 
says the coinsurance has processed correctly for these claims. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a total cost share of $110.64 for the Methylprednisolone, Euflexxa, and Vitamin 
B12. The services provided fall within the Medicare Part B prescription drugs 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 coinsurance for the Methylprednisolone injection (J1030), Euflexxa injection 
(J7323), and Vitamin B12 injection (J3420) provided from June 23, 2020, to August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on October 8, 2020, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not 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 had network providers 
available who could have provided 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 lab work provided on October 8, 2020, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for the oral exam (D0120) and prophylaxis (D1110) provided on 
September 18, 2018. 
 
You asked the Plan to reimburse you for the dental services. You say that the claim from 2018 was denied 
because it was filed past the time limit. You say that the dental plan representative advised that you would not 
know about the limit since claims are usually submitted by the provider. You also say that you should be 
reimbursed for the services you received in 2018. The Plan denied your request. The Plan says that the claim 
was submitted beyond the 1 year timely filing requirements. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage have been met. The Evidence of Coverage clearly states that you must submit your claim within 3 
years of the date of service. Therefore, we decided that the Plan has to reimburse you for the oral exam 
(D0120) and prophylaxis (D1110) provided on September 18, 2018.  
 
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 compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have poor blood circulation on 
both legs. The Plan denied your request. The Plan says compression stockings are only covered for the 
treatment of open venous stasis ulcers. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair provided on August 25, 2020. 
 
You asked the Plan to pay for the wheelchair. You say that this is the best chair for your situation. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that that you receive your care from a provider who is eligible to provide services under Original 
Medicare. 
 
The provider in this case is not a network provider with the Plan. The records do not show that the provider is 
eligible to provide services under Original Medicare. The Plan did not pre-approve the wheelchair. We found 
no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have 
to pay for the wheelchair provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction rendered on August 11, 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 were not routine. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers an eye refraction when it is part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The file shows that the eye refraction was not performed as part of a 
routine eye exam but for a diagnosis of age-related cataracts. 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 pay for the eye refraction rendered on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the Group 3 PWC. You say that you believe this is medically necessary. The 
Plan denied your request. The Plan says the specific type of PWC being requested is not covered by Medicare 
for your condition. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 
30, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that these services should 
be covered in full. The Plan denied your request. The Plan says the total $78 amount applied correctly as your 
liability. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation and prophylaxis provided on July 30, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz XR tab 11mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medication was denied due to a benefit exclusion. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeljanz XR tab 11mg for 
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist/hand/finger orthosis (L3808) provided to the enrollee 
on July 15, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not include a valid physician order; therefore, the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of HCPCS code L3808 is "Wrist hand finger orthosis, rigid 
without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
provider did not meet DMEPOS guidelines in order to ensure reimbursement.  There is no valid physician 
order included in the medical documentation, therefore, this service cannot be validated. 
 
We looked at this coder'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 pay for a wrist/hand/finger orthosis (L3808) provided to the enrollee on July 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services provided 
by a participating provider from January 7, 2020, to January 31, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient rehabilitation services. You say that you cannot 
afford these payments. You say that you are on disability. The Plan denied your request. The Plan says the 
correct coinsurance has been 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 20% 
coinsurance for outpatient rehabilitation services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for outpatient rehabilitation services. 
The allowed amount is $576.57. The total amount you are being asked to pay is $115.32 ($576.57 x 20% = 
$115.32). Outpatient rehabilitation services falls within the outpatient 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 coinsurance for outpatient rehabilitation services provided by a 
participating provider from January 7, 2020, to January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided to the 
enrollee on August 19, 2020. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this was medically necessary. 
The Plan denied your request. The Plan says that this  is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery, at home, or in any setting. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device (E0676) provided to the enrollee on 
August 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forthe chest x-ray provided to the enrollee on May 23, 2020 and billed under code 71046-26. You asked the Plan to pay this claim. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan stated that this claim denied because the they previously paid for this service under another claimfor a provider in the same radiology group. The Plan states there was not a modifier submitted with the claim to show a separate and distinct service. The Plan states the issue was not whether the service was provided, but that it was submitted incorrectly based onprevious services billed. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician inthe same specialty in the same group,only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay forthe chestx-ray provided to the enrollee on May 23, 2020 under code 71046-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for arthrocentesis provided on September 24, 
2020, and October 1, 2020. 
 
You asked the Plan to waive the copayments for arthrocentesis. You say that you disagree with the surgery 
charges. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received Arthrocentesis on September 24, 2020. Arthrocentesis is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the allowed amount of $292.87, which is less than the $300 
copayment.   
 
You received Arthrocentesis on October 1, 2020. Arthrocentesis is considered an outpatient surgical procedure. 
Therefore, you are responsible to pay the allowed amount of $292.87, which is less than the $300 copayment.   
 
The total amount you owe is: $585.74. 
 
You have been asked to pay the total copayment amount of $585.74 for arthrocentesis. Arthrocentesis falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 arthrocentesis provided on 
September 24, 2020, and October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on August 
11, 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 inpatient claims must be billed with POS code 
21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue. The claim was incorrectly billed with POS code 22 for outpatient hospital. 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 magnetic resonance imaging (MRI) rendered on August 
11, 2020.