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

We decided that the Plan does not have to pre-approve a bilateral lower extremity arterial duplex examination.
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 enrollee has non-lifestyle limiting bilateral lower extremity pain, throbbing, swelling, cramping, and achiness that is present at rest and after short distance ambulation. He notes that the symptoms are not limiting his activity and productivity. On physical examination, he has palpable pedal pulses bilaterally and the right popliteal pulse is stronger than the left. An abnormal ABI or extremity arterial Doppler study is not provided in the medical records. The records do not support that the bilateral lower extremity arterial duplex examination is reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral lower extremity arterial duplex examination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
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 maxillary partial denture - cast
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot be
determined how the enrollee came to the servicing provider.
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 and confirm that
Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The documentation submitted does not contain medical records from
the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been
met. 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 the services provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on
December 12, 2019.
You asked the Plan to waive the coinsurance for the Euflexxa injection. You say that at the time of the visits,
you were informed there would be no additional charges. You say that you are being overcharged. The Plan
denied your request. The Plan says the coinsurance applied correctly.
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 20% of
the cost for Part B-covered drugs covered under Medicare Part B.
You have been asked to pay $29.71, which is 20% of the allowed amount for the Euflexxa injection. The
allowed amount is $148.54 (20% x $148.54 = $29.710. The Euflexxa injection falls 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
Euflexxa injection provided on December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee
beginning June 25, 2020.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee needs this
to provide support and maintain safety. The Plan denied your request. The Plan says that there is no evidence
provided that member's treatment needs could not be met at a less restrictive.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the
enrollee. The enrollee can be treated in a lesser restrictive setting as he was not showing any suicidal or
homicidal ideation, auditory or visual hallucinations, delusions and was not showing any abnormal behaviors,
being cooperative and compliant while not showing any acute threats to safety. Our physician reviewer found
that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee beginning
June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
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 you have a diagnosis of prostate cancer.
Proton beam therapy is not recommended for prostate cancer outside of a prospective clinical trial or registry.
The use of proton beam therapy over standard intensity modulated radiation therapy (IMRT) for routine cases
is considered investigational in nature. Proton beam therapy is not reasonable or 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 proton beam therapy.
Local Coverage Determination (LCD) L34224 referenced by the Plan is for stereotactic body radiation therapy
(SBRT) and was not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued personal home care services.
You asked the Plan to pre-approve these services. You say that you still need services for open wounds that
won't heal and need to be dressed. The Plan denied your request. The Plan says you have exhausted the benefit
limit.
The Plan must follow Medicare rules. The rules say that custodial care is not covered by Medicare. The
contract with the Plan says that you are covered for up to 42 hours per year of personal home care services.
We looked at the file and Medicare rules. The file shows that you have used all 42 hours of personal home care
services allowed by the Plan. Further services are not covered by Medicare or your supplemental benefit with
the Plan. Therefore, we decided that the Plan does not have to pre-approve continued personal home care
services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs from January 13, 2020 through
January 14, 2020.
You asked the Plan to pay for self-administered drugs. You say that you were not able to give a self-given drug
as it is against hospital policy. The Plan denied your request. The Plan says the Medicare rules have not been
met.
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 self-administered drugs have not been met. Review of the file show
that you were in an outpatient setting and Medicare nor the health plan cover self-administered drugs in the
outpatient setting under Medicare Part B. Therefore, we decided that the Plan does not have to pay for selfadministered
drugs from January 13, 2020 through January 14, 2020.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from October 2, 2019
through October 3, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.
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 services have not been met.
The claim was billed with a clinical trial procedure, procedure 02RF38Z  Replacement of Aortic Valve with
Zooplastic Tissue, Percutaneous Approach and was not billed with a clinical trial number. On April 14, 2020
and April 20, 2020, the plan attempted to obtain a clinical trial number but one was not received. As a valid
clinical trial number was not billed on the claim, we find the Medicare rule for payment of this October 02,
2019 through October 03, 2019 inpatient facility claim has not been met. If the provider determines that a
billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a
corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for
the services provided to the enrollee from October 2, 2019 through October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that you need an explanation as to how
you can receive the results of the mammogram when the appointment with the referring physician was denied.
The Plan denied your request. The Plan says your Plan requires you to receive care from providers who are part
of your primary care physician's (PCP) specialty 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical vision services provided on September 23, 2019.
You asked the Plan to waive the copayment for the medical vision services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the medical vision services on September 23, 2019. You were asked to pay a $35 copayment for the services. You already paid $10.84 toward the copayment, therefore, you are asked to pay the remainder of the copayment which is $24.16. 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 medical vision services provided on September 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the clinical assessment and medical
records support that the enrollee requires LTACH services and is ready for transfer from the current facility.
The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted and treated for acute respiratory failure and pneumonia.
The enrollee is currently somnolent, confused, and is requiring supplemental oxygen via tracheostomy,
antibiotics, PEG tube feeds, wound care, lung treatments, and monitoring. The enrollee is currently receiving
appropriate care, which appears to be needed in an acute care facility for at least a short while longer, due to the
enrollee not being alert. Discharge to a lower level of care may be reasonable in time. The enrollee does not
require any services at the LTACH which are not already available at the current acute care facility.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 50389) provided to the enrollee on
November 5, 2019.
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 this was reported without the required anatomical modifier.
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 code 50389 is "Removal of nephrostomy tube, requiring
fluoroscopic guidance (eg, with concurrent indwelling ureteral stent)."
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 coded correctly. Our coding reviewer found the documentation does not
specify the anatomical location with an appropriate modifier - LT (left side), RT (right side) or 50 (bilateral).
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 surgical services (CPT 50389) provided to the enrollee on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the anesthesia provided on December 30,
2019.
You asked the Plan to reduce the coinsurance for the anesthesia. You say that you were not aware the provider
was out-of-network. You say you would like the claim processed as in-network. The Plan denied your request.
The Plan says you have been charged the correct cost sharing 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 50% of
the Medicare-allowed amount at an out-of-network outpatient hospital facility.
You have been asked to pay $28.36 which is 50% of the allowed amount for the anesthesia. The allowed
amount is $56.73. ($56.73 x 50% = $28.36). The anesthesia 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 reduce the coinsurance for the anesthesia provided on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from October 31,
2018 to November 3, 2018.
You asked the Plan to pay for inpatient hospital services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services were unauthorized post-stabilization care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for inpatient hospital services. Our reviewer
says that the enrollee was stable for transfer to a network hospital. Our physician reviewer found the submitted
records show that the enrollee was hemodynamically stable and appropriate for ambulance transport with
monitoring to a Plan facility after the emergency room evaluation on October 31, 2018. There is no
documentation indicating that the enrollee was unstable for transfer. The post-stabilization services were not
medically necessary and the treating physician did not document that the enrollee was unstable for transfer on
any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pay for the inpatient hospital services rendered from October 31, 2018 to November 3,
2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says hospital records show that medical conditions have improved, and care can be safely
received in a less intensive setting.
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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does require skilled physical therapy and occupational therapy but based on the medical records provided the
enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical
records provided there no indication of a need for the intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with home health
services appears to be more appropriate in this case.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Forteo.
You asked the Plan to pre-approve Forteo. You say that the enrollee is being treated for osteoporosis. The Plan
denied your request. The Plan says medicines that are injected by an enrollee to themselves is not covered
under the medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Forteo.
Benefits for Forteo may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Fluorodeoxyglucose (FDG) Positron Emission Tomography
(PET) scan.
You asked the Plan to pay for the FDG PET scan. You say that this imaging should be allowed in order to
assess the regional lymph node status in order to plan for treatment. The Plan denied your request. The Plan
says Medicare does not cover PET imaging for initial anti-tumor strategy for prostate cancer patients.
The Plan follows Medicare rules. Medicare rules say that PET imaging for initial anti-cancer strategy is
noncovered for enrollees with prostate cancer. Therefore, we decided that the Plan does not have to pay for
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan.