Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 8, 2022, through 
May 10, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on May 8, 2022 with generalized 
abdominal pain, cramping, nausea, and non-bloody diarrhea. The enrollee was evaluated by Gastroenterology 
who recommended a course of five days of antibiotics. The enrollees diet was advanced, which was tolerated. 
The enrollee was felt to be medically stable on May 9, 2022. The review has determined that the record showed 
that at the time of the inpatient admission, the admitting physician reasonably expected that the enrollees 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from May 8, 2022, through May 10, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment program services provided from 
June 13, 2022, to June 27, 2022. 
 
You asked the Plan to pay for opioid treatment program services. The Plan denied your request. The Plan says 
the services were billed by a non-physician practitioner who cannot bill directly. Also, per the CMS taxonomy 
crosswalk, the taxonomy listed on the claim is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for opioid treatment program services provided from June 13, 2022, to  
June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on October 06, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not have a lesion 
destruction performed. The Plan denied your request. The Plan says this cost sharing was charged 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 physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) 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. The file shows that there is no 
responsibility for the lesion destruction charge, only the copayment for the specialist office visit. Therefore, we 
decided that the Plan does not have to waive the copayment for the office visit provided on October 06, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on July 
30, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided on July 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an ultraviolet light therapy box for home use.
You asked the Plan to provide coverage for an ultraviolet light therapy box for home use. You say that at the time of the appeal, the request to have this equipment for use at home was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that home equipment is only covered in specific circumstances. The Plan states the Maximus review is inconsistent as it stated the records show your type of psoriasis responds well to a high potency topical corticosteroid.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only covers this equipment for home use in special circumstances. The medical records do not show that you are unable to receive this treatment outside of the home as you are not clinically homebound. Medicare rules for coverage of this equipment were not met. Therefore, we decided that the Plan does not have to provide coverage for an ultraviolet light therapy box for home use.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthopedic appointment provided on August 16, 2022. 
 
You asked the Plan to pay for an orthopedic appointment. You say that you didnt know this provider was out-
of-network, and did not know you needed a referral. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). There was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for an orthopedic appointment provided on August 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from October 15, 2022, 
to October 17, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the hospital knew your insurance and 
you had no control over the tests they ran. You also say that you live on social security, and cannot afford a 
bill. The Plan denied your request. The Plan says you were provided Acetaminophen, aspirin, Atorvastatin, 
Diphenhydramine, Levothyroxine Sodium, Nitroglycerin 2% ointment, Pantoprazole, Pramipexole 
Dihydrochloride, Metoprolol, Rivaroxaban, and Verapamil, which are self-administered medications not 
covered under Part B. 
 
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 from October 15, 2022, to October 17, 2022.   
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the service is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is at 
high risk for breast cancer based upon her multicentric DCIS and family history.  The request for bilateral 
breast MRI is reasonable based upon her own and family history. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have been met. Therefore, we decided that 
the Plan has to pre-approve magnetic resonance imaging (MRI).  
 
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 an acute inpatient hospital admission for a left shoulder 
arthroplasty. 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 this service. Our reviewer says that the 
requested service is not medically necessary.  Our physician reviewer found that the enrollee is undergoing a planned elective left shoulder surgery. He is 
medically stable with a past medical history of Hypertension. The planned procedure listed under current 
procedure terminology (CPT) code 23472 is not listed on the Centers for Medicare and Medicaid Services 
(CMS) Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation that the enrollee will require greater than a two midnight 
stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an acute inpatient hospital admission for a left shoulder arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical procedure performed in a 
specialist office provided on September 02, 2022. 
 
You asked the Plan to waive the copayment for a surgical procedure performed in a specialist office. You say 
that you thought there would not be a copayment for a surgical procedure. The Plan denied your request. The 
Plan says this cost sharing was charged 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 $10 
copayment for physician/practitioner service. 
 
You have been asked to pay a $10 copayment for a surgical procedure performed in a specialist office. This 
item/service falls within the physician/practitioner 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 surgical procedure performed in a specialist office provided on September 02, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 22, 2022, through 
May 27, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on May 22, 2022. The evaluation in the 
ED revealed hematuria. The computed tomography (CT) scan of the brain provided was normal and the CT 
scan of the chest provided was negative for a pulmonary embolism. The enrollee was started on intravenous 
antibiotics and was admitted. She was evaluated by Cardiology. While on telemetry she had an 8 beat run of 
ventricular tachycardia. Her condition stabilized and improved and she was discharged back to the nursing 
facility on May 27, 2022. The review has determined that the record showed that at the time of the inpatient 
admission, the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from May 22, 2022, through May 27, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure. 
 
You asked the Plan to pre-approve Repatha Sure. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Repatha Sure is not covered under the enrollee's Medicare 
Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sure.  
 
Benefits for Repatha Sure 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 23, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on June 27, 2022. 
 
You asked the Plan to pay for the telehealth visit. You say that authorization could not be obtained due to 
staffing issues. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telehealth visit 
provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213), electrical stimulation (G0283), and 
the extraspinal chiropractic manipulative treatments (98943) provided from January 6, 2022, through  
February 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits (99213), electrical stimulation (G0283), and the 
extraspinal chiropractic manipulative treatments (98943) provided from January 6, 2022, through February 25, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921), and topical 
application of fluoride varnish (D1206) provided on September 22, 2022. 
 
You asked the Plan to pay for gingival irrigation  per quadrant (D4921), and topical application of fluoride 
varnish (D1206). You say that you have submitted information showing you have had this procedure done two 
times a year and the correct code is D4910. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 gingival 
irrigation  per quadrant (D4921), and topical application of fluoride varnish (D1206) provided on September 
22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81355, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 12, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81355, 0031U, 
0032U and 0033U.