Persius/hicric huggingface dataset:
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 an LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and does not require transfer to an LTACH. 
 
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 that the enrollee was admitted to the current acute care hospital with an abdominal 
aortic aneurysm (AAA), mesenteric ischemia status post a superior mesenteric artery (SMA) stent and right 
brachial primary repair and thromboembolectomy. The course was complicated by unresponsiveness after a 
right internal jugular (IJ) removal. The AAA was repaired with hernia repair and colostomy as well as bilateral 
thrombectomy, however, she required extended intubation until recently when she was extubated. Recent notes 
show she is improving neurologically and tolerating a continuous positive air pressure (CPAP) device. The 
patient appears to be stabilizing, but requires additional short term acute care services to help further stabilize 
including additional weaning which can safely be completed in the current facility and is likely to not exceed 
an additional twenty four days. The patient does not require services in the LTACH that are not already 
available at the current facility. There are no services at the LTACH that are not already available and covered 
at the current facility. Therefore, this request for LTACH services will be considered not medically necessary 
at this time. Transfer may be considered when the treatment has completed and the patient is stable and 
appropriate for 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back brace for the enrollee. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says the submitted office notes do not mention chronic back pain. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a spinal orthosis (L0650) is not medically necessary. There is no evidence on a physical exam that the 
patient receives reduced pain with trunk mobility restriction or that the patient has subjective complaints of 
back pain with trunk mobility. There is no evidence of an injury or surgery to the spine or related soft tissues 
that requires healing or that there is a weak and/or deformed spine. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a back brace for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 7, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral 
periapical x-ray, removal of residual tooth roots, limited oral evaluation, and preventive procedure provided on 
May 26, 2020 by an OON provider. 
 
You asked the Plan to pay for the intraoral periapical x-rays, removal of residual tooth roots, limited oral 
evaluation, and preventive procedure provided on May 26, 2020.. You say that you contacted the plan prior to 
the services being rendered, and were told this provider was in-network. The Plan denied your request. The 
Plan says these services were rendered by an OON provider. The Plan also says that they were contacted by the 
provider's office on this date of service, and were advised that you do not have OON coverage.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefi t 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 
covered when they are received OON. The records show that on May 22, 2020, you called the Plan inquiring 
about seeing a dentist in Rhode Island (RI), and you were advised that you do not have benefits in RI. 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional  
intraoral periapical x-ray, removal of residual tooth roots, limited oral evaluation, and preventive procedure 
provided on May 26, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on June 23, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 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. 
 
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 
outpatient hospital 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 outpatient hospital services provided on June 23, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the defibrillator implant provided on July 
10, 2020. 
 
You asked the Plan to waive the coinsurance for the defibrillator implant. You say that you were informed the 
supplemental benefits pick up the 20%. You say that insurance should take care of the fee.  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% 
coinsurance for surgery services at an in-network outpatient hospital or ambulatory surgical center. 
 
You have been asked to pay $5,268.68, which is 20% of the allowed amount for the defibrillator implant. The 
allowed amount is $26,343.41 (20% x $26,343.41 = $5,268.68). The defibrillator implant 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 coinsurance for the defibrillator implant 
provided on July 10, 2020.  
 
  
 
 
Your complaint about this being a scam is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided June 4, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that CMS has issued guidance allowing 
independent freestanding emergency departments to provide care to Medicare and Medicaid beneficiaries 
during the COVID 19 public health emergency. The Plan denied your request. The Plan says this facility is a 
non-Medicare approved/certified freestanding emergency facility. Freestanding emergency rooms are not 
hospitals and have no affiliation with a hospital and are unable to obtain Medicare approval/certification. 
 
The Plan must follow Medicare rules. Medicare does not certify freestanding emergency rooms or recognize 
them as departments since they cannot demonstrate compliance with hospital Conditions of Participation 
(COP). Therefore, independent freestanding emergency rooms cannot accept Medicare or receive Medicare 
reimbursement. According to Chapter 15, Section 15.1 of the Medicare Program Integrity Manual, no provider 
or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and 
supplier enroll in the Medicare program.  Additionally, Medicare guidance allowing payment on emergency 
hospital claims for non-Medicare certified hospitals does not apply to non-Medicare freestanding emergency 
facilities. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have 
to pay for emergency room services provided June 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable wireless pulmonary artery pressure sensor 
with delivery catheter (CPT Codes: 33289 and C2624). 
 
You asked the Plan to pre-approve the services. You say that the member needs this device and procedure due 
to their worsening heart failure. The Plan denied your request. The Plan says this procedure is considered to be 
experimental and investigational due to a lack of scientific evidence regarding the safety and effectiveness of 
adults with heart failure. 
 
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 services. 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 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantable wireless pulmonary artery pressure sensor with delivery catheter (CPT Codes: 
33289 and C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on July 22, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the OON pathology services. You say that the records should be reviewed for 
medical necessity and to allow payment for these services. The Plan denied your request. The Plan says these 
services were provided without prior authorization by an OON provider. The services were not referred or 
ordered by a network provider, nor was the sample taken in an in-network facility. 
 
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 surgical pathology services provided on July 
22, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a lumbar-sacral orthosis (L0650). You say that the claim should be paid. The 
Plan denied your request. The Plan says they did not pre-approve the services at issue. 
 
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 medical services provided on June 17, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions (D7311) 
provided on July 7, 2020. 
 
You asked the Plan to pay for the alveoloplasty in conjunction with extractions. You say that this service 
should be covered. The Plan denied your request. The Plan says this service is clearly excluded from your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
alveoloplasty in conjunction with extractions (D7311) provided on July 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on May 28, 2020 through June 10, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that the facility does not deserve any 
payment due to the quality of care you received. The Plan denied your request. The Plan says the cost share is 
correct. 
 
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 
copayment per day, days 1-20 for each SNF stay for skilled nursing facility (SNF) care.  
 
You have been asked to pay $20 copayment per day, days 1-20 for each SNF stay for SNF care ($20 x 13 
days= $260). This service falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care provided on May 28, 2020 
through June 10, 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: Lab
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 March 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on August 12, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. 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. The 
Plan says that these services could have been provided in-network. 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 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 specialist services provided on August 12, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bariatric surgery provided on June 29, 2020. 
 
You asked the Plan to pay for the bariatric surgery. You say that the enrollee was experiencing issues that were 
affecting quality of life. The Plan denied your request. The Plan says information provided does not support 
coverage criteria for the surgery. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees 
who have:  
 
(1) a body mass index (BMI) of greater than or equal to 35;  
 
(2) at least one co-morbidity related to obesity; and 
 
(3) been unsuccessful with medical treatment for obesity.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the bariatric surgery. Our reviewer says that 
the service was not medically necessary. Our physician reviewer found the case file does not contain 
documentation supporting that medical treatment of the enrollee's obesity was unsuccessful. 
 
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 bariatric surgery have not been met. Therefore, we decided that the Plan 
does not have to pay for the bariatric surgery provided on June 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care related to an elective cardiac 
surgery provided in an out of network (OON) facility from September 5, 2019 to September 6, 2019. 
 
You asked the Plan to pay for the OON inpatient care. You say that the enrollee was found to require this 
cardiac surgery and the care provided was medically reasonable and necessary. The Plan denied your request. 
The Plan says this was a scheduled elective surgery. Authorization was not requested to have this provided at 
an OON facility and there were network facilities available. 
 
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 inpatient hospital care related to an elective 
cardiac surgery provided in an out of network (OON) facility from September 5, 2019 to September 6, 2019.