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

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 17, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
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 the medical services provided to the enrollee by an out-of-network provider 
on June 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee surgery. 
 
You asked the Plan to pre-approve knee surgery. 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 knee surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence based medical literature does not support surgical intervention at this time. 
This is based on the lack of significant mechanical knee issues and significant degree of medial compartment 
degenerative changes (noted by orthopedist as being moderate). Therefore, the requested right knee arthroscopy 
with meniscal repair is not medically reasonable and 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 knee surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pelvis/hip joint surgery (27299) provided on August 28, 
2019. 
 
You asked the Plan to pay for the surgery. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the billed procedure code 27299 does not appear on 
Addendum AA for covered surgical procedures including surgical procedures for which payment is packaged 
and is found under the Addendum EE Surgical Procedures Finalized to be Excluded from Payment. 
 
The Plan must follow Medicare rules. Medicare rules say that covered ASC services are those surgical 
procedures that are identified by CMS on a listing that is updated at least annually. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgery have not been met. Specifically, CPT code 27299 is listed as a surgical procedure 
finalized to be excluded from payment for an ASC. Therefore, we decided that the Plan does not have to pay 
for pelvis/hip joint surgery (27299) provided on August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services (A0432) provided June 18, 
2020. 
 
You asked the Plan to pay for the paramedic intercept services. You say that the enrollee was taken by 
ambulance from a nursing home where she resided. If it was not for the pandemic you would have taken her to 
the ER yourself. The Plan denied your request. The Plan says this service is not covered per Medicare 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the paramedic company does not have a contract with the volunteer ambulance 
company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services (A0432) provided June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses represented by codes L1971, L3170, L1851 and 
L2397 provided to the enrollee on March 25, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the orthoses represented by codes L1971, L3170, L1851 and L2397 provided to 
the enrollee on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for straight knee joint, heavy duty (L2385) provided April 14, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says the records do not support the billed 
service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or itemized shipping/billing invoice for the supplies 
provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed item. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for straight knee joint, heavy duty (L2385) provided April 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from May 1, 2020, to May 3, 2020. 
 
You asked the Plan to pay for inpatient care. You say that this should be covered. The Plan denied your 
request. The Plan says this provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider of the services at issue is not shown to be enrolled in 
Medicare. Based on this information, we decided that Medicare rules for coverage of inpatient care have not 
been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from May 1, 
2020, to May 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
April 29, 2019. 
 
You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration 
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating 
room throughout the duration of the procedure. The Plan denied your request. The Plan says payment for this 
service is the responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pump operation and assembly have not been met. Specifically, payment for this service is 
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, 
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
April 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on December 3, 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 Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for rectal cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Guardant360? molecular pathology genomic profiling provided to the enrollee on December 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 10, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the nurse would not let you take the 
medications you brought from home. The Plan denied your request. The Plan says self-administered drugs are 
not covered under Part B of Original Medicare. 
 
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 pay for the self-administered drugs 
provided on May 10, 2020.  
 
Benefits for the 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to make additional payment for the glasses. We decided that the Plan does not 
have to make additional payment for the extended warranty.  
 
You asked the Plan to make additional payment for the glasses and warranty. You say that you would like 
reconsideration because you were told this service would be covered. The Plan says that your copayment has 
been applied correctly. 
 
We decided that the Plan has to make additional payment for the glasses. 
 
The Plan contract says that you have a $250 allowance for frames and lenses once per calendar year.  
 
The record does not indicate that this allowance has been previously used. The Plan is responsible for paying 
$250. The allowed amount for this service is $265.99. You cannot be asked to pay more than $15.99 (265.99-
250.00). Therefore, we decided that the Plan has to make additional payment for the glasses and warranty.  
 
We also decided that the Plan does not have to make additional payment for the extended warranty. 
 
The Plan contract says that if you get services that are excluded (not covered), you must pay for them yourself.  
 
The extended warranty is not a covered benefit under Medicare or the Plan. Therefore, we decided that the Plan 
does not have to make additional payment for the extended warranty. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is felt that the enrollee requires a higher level of 
rehab care. The Plan denied your request. The Plan says the enrollee's condition does not require frequent 
physician oversight in a hospital setting nor an intensive therapy program. 
 
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 enrollee is a male with a history of meningioma who was transferred to the 
hospital on 9/23/2020 due to right arm weakness and recurrent meningioma. He underwent a repeat 
craniotomy. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee 
is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The 
enrollee's care needs can be met at a lower level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 13, 2019. 
 
You asked the Plan to pay for the physician's 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 
physician's 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 physician's services provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Premetrexed injections you received 
on February 3, 2020, and February 24, 2020. 
 
You asked the Plan to waive the coinsurance for the Premetrexed injections. You say that you are surprised that 
this charge is so high. The Plan denied your request. The Plan says you were charged this coinsurance 
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% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Premetrexed injections. The Medicare-allowed amount 
for each injection is $10,346.29. Therefore, for each date of service, your 20% coinsurance obligation is 
$2,069.26 (for a total of $$4,138.52 for both dates of service). The Premetrexed injections fall within the 
Medicare Part B 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 
Premetrexed injections you received on February 3, 2020, and February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on May 23 to 
May 24, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not consent to 
be taken to the hospital. 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 $350 
copayment for each day of days 1-4 of each admission.  
 
You have been asked to pay a $350 copayment for an inpatient hospital stay. An inpatient hospital stay 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 an inpatient hospital stay on May 23 to May 24, 2020.  
 
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 waive the copayment for a CT scan provided by a participating 
provider on May 22, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you did not have a CT scan done. The 
Plan denied your request. The Plan says the correct copayment 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 $225 
copayment for outpatient diagnostic tests/advanced imaging service.  
 
You have been asked to pay a $225 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests/advanced imaging service 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 
CT scan provided by a participating provider on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions provided on November 4, 2019. 
 
You asked the Plan to pay for the extractions. You say that you didn't understand the contract status of the 
provider. The Plan denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extractions provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on May 5, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 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 the established patient office or other outpatient 
visit (99214) provided on May 5, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00104) provided on June 21, 2019 
through August 1, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says medical necessity of this service cannot be 
determined. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Specifically, the submitted documentation does not 
include sufficient information such as medical records to determine whether payment is due or the amount of 
payment. Of note, the record indicates that the Plan made diligent efforts to obtain records and none were 
received. Therefore, we decided that the Plan does not have to pay for anesthesia services (00104) provided on 
June 21, 2019 through August 1, 2019.