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

 
We decided that the Plan does not have to waive the copayment for an urgent care facility visit on February 9, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care facility visit. You say that you should not be 
responsible to pay this because you were told there would be no charge. The Plan denied your request. The 
Plan says that the copayment amount you are being charged is correct. The Plan also says that they reprocessed 
and reduced the copayment amount from $50 to $25. 
 
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 $25 
copayment for each urgent care facility visit.  
 
You have been asked to pay a $25 copayment for an urgent care facility visit. An urgent care facility visit falls 
within the Urgently Needed 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 copayment for 
an urgent care facility visit on February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychiatric partial hospitalization. 
 
You asked the Plan to pre-approve a psychiatric partial hospitalization. You say that you do not agree with the 
Plan's denial. The Plan denied your request. The Plan says the case does not demonstrate that your life is at risk 
or in jeopardy, there is no evidence of suicidal thoughts. The Plan also says that you do not represent a risk of 
homicidal behavior, no psychotic episodes are reported, and the case can be managed with more frequent visits 
to the psychiatrist. 
 
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 psychiatric partial hospitalization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you were not showing any dangerousness to yourself or others and have 
not been exhibiting severe psychological or psychiatric impairment requiring this level of care. You were 
tolerating medication and not showing any perceptual disturbance, psychosis or aggressive behaviors. Our 
reviewer also found it does not appear medically necessary and reasonable to have psychiatric care provided at 
the partial hospitalization level of care rather than a lower level of care, as you do not have any suicidal or 
homicidal thoughts or behavioral disturbance and your symptomatology could be treated 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 a psychiatric partial hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a psychiatric partial hospitalization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81436, 81435) provided on April 5, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says genetic testing for screening purposes is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that screening services such as pre-symptomatic 
genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare 
benefit and are not covered. 
 
We looked at the file and Medicare rules. The service was for screening purposes and records show no personal 
cancer diagnosis. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81436, 81435) 
provided on April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical navigation 
for an orthopedic procedure. 
 
You asked the Plan to pre-approve the computer-assisted musculoskeletal surgical navigation for an orthopedic 
procedure. You say that you are in need of knee surgery so that you can walk better. The Plan denied your 
request. The Plan says the requested procedure is considered 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 computer-assisted musculoskeletal 
surgical navigation for an orthopedic procedure. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that you are being 
treated for unilateral primary osteoarthritis of the left knee. You presented with left knee pain and swelling. 
You had 100% relief for 2 weeks with the cortisone injection in April. The exam reveals an antalgic gait. The 
knee demonstrates a mild effusion. Range of motion is 5 to 110. X-rays are noted to show severe osteoarthritis 
with joint space narrowing, subchondral cyst formation, sclerosis and osteophyte formation particularly of the 
medial compartment. There are no large volume, long term/high quality clinical studies that confirm clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over 
standard surgical approaches in total knee arthroplasty. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 computer-assisted musculoskeletal surgical navigation for an orthopedic 
procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve computer-
assisted musculoskeletal surgical navigation for an orthopedic procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements: transosteal implants (D6050 
x2) for tooth #'s 29 and 31, two abutment supported porcelain/ceramic crowns (D6058 x2) for tooth #'s 29 and 
31, and a pontic (D6240) for tooth #30. 
 
You asked the Plan to pre-approve the transosteal implants, abutment supported porcelain/ceramic crowns, and 
pontic. The Plan denied your request. The Plan says the transosteal implants and abutment supported 
porcelain/ceramic crowns are not covered under the enrollee's benefit plan. The Plan also says that a pontic 
cannot be approved because the enrollee is missing other teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers pontics when 
the services are medically necessary and reasonable.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pontic. Our reviewer says that a 
pontic (D6240) for tooth #30 does not meet the criteria for coverage. Our physician reviewer found a pontic 
needs abutments. Our reviewer also found if the abutments are excluded from coverage, the pontic is not 
covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the transosteal implants, abutment supported porcelain/ceramic crowns, and 
pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve two surgical 
placements: transosteal implants (D6050 x2) for tooth #'s 29 and 31, two abutment supported porcelain/ceramic 
crowns (D6058 x2) for tooth #'s 29 and 31, and a pontic (D6240) for tooth #30.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not see the enrollee is not able to use the preferred drug Remicaid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 medication. Our physician reviewer 
found the record does not indicate that the enrollee has a contraindication to or would have an adverse effect 
from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Renflexis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee brace (L1833) provided on 
September 14, 2021. 
 
You asked the Plan to waive the coinsurance for a knee brace. You say that the item at issue was a medical 
necessity for you. The Plan denied your request. The Plan says the correct coinsurance 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 20 percent coinsurance for each Medicare-covered item of durable medical equipment and related supplies.  
 
You have been asked to pay $98.61, or 20 percent of the Medicare-allowed charge of $493.07, for a knee 
brace. A knee brace falls within the Durable Medical Equipment (DME) and Related Supplies 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 a knee brace (L1833) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits and x-rays provided 
January 13, 2022, to February 16, 2022. 
 
You asked the Plan to waive the copayments for specialist visits. You also asked the Plan to waive the 
copayments for x-rays. You say that you should not be responsible to pay this. The Plan denied your request. 
The Plan says the cost share has been 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 a $35 
copayment for the consultation, diagnosis, and treatment by a specialist. Your contract with the Plan also 
clearly says that you must pay a $15 copayment for x-rays. 
 
 
 You have been asked to pay $100 for specialist visits and x-rays. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. X-rays fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 specialist visits and x-rays provided January 13, 2022, to February 16, 2022.  
 
 
Date of Service CPT Code Amount Billed Amount 
Allowed 
Plan Paid Cost Share 
      
1/13/2022 99213 $144.00 $88.29 $53.29 $35.00 
1/13/2022 73650 $82.00 $23.40 $8.40 $15.00 
2/16/2022 99213 $144.00 $88.29 $53.29 $35.00 
2/16/2022 73650 $79.00 $19.56 $ 4.56 $15.00 
      
Total   $219.54 $119.54 $100.00
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee would benefit from continued 
therapy. The Plan denied your request. The Plan says that additional physical therapy is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the clinical documentation shows that the 
enrollee has not met all reasonably appearing therapy goals and would require the assistance and treatment of a 
professional therapist to meet thus 10 additional outpatient physical therapy sessions are 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 therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve 10 physical therapy visits.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
   
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need extensive assistance to get back to your 
prior level of independence. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
SNF coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for critical care services and visits provided to the enrollee on July 18, 
2021. 
 
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 that medical necessity cannot be established. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has said that multiple attempts were made to obtain medical records in 
this case. However, the plan did use previous medical records to come to their decision in this case. The case 
file shows that records from previous admissions were used in their decision. The plan did not provide these 
records for review to MAXIMUS. Therefore, we decided that the Plan has to pay for critical care services and 
visits provided to the enrollee on July 18, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation on May 4, 2022. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that you were referred to this 
dentist by your general dentist and you thought the provider would be in-network. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
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, 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 
comprehensive periodontal evaluation on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says The Plan says Current Procedural 
Terminology (CPT) code 83789-59 (1 unit) remains not supported based on the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept back procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept back procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 intracept back procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show 
safety and efficacy. 
 
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 intracept back procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the intracept back procedure (CPT code(s): 64628 and 64629).