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

 
We decided that the Plan does not have to pay for the ambulance services (A0428) provided on November 27, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this 
service was billed correctly. The Plan denied your request. The Plan says this service was not billed with an 
appropriate revenue code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code A0428 is not supported in the record. Specifically, this claim was not billed with the 
required revenue code for ambulance services. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for the ambulance services (A0428) provided on November 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided by a participating provider on 
August 2, 2021, to August 23, 2021. 
 
You asked the Plan to pay for physical therapy. You say that you would like approval for these services. The 
Plan denied your request. The Plan says medical records were not provided to show medical necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy provided by a participating provider on August 2, 2021, to August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need to appeal to have the crowns done 
on your teeth instead of fillings due to already existing decay on your teeth. You also say that the procedure 
definitely needs to be done before you lose any more of the tooth. The Plan denied your request. The Plan says 
your plan does not cover this procedure. 
 
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 pre-approve an 
occlusal guard (D9944).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not 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 the physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the additional requested therapy generally is not 
accepted as specific and effective therapy for the patients condition beyond what was approved by the plan. 
The patient has had prior therapy and the documentation does not reveal that the patient has completed the 
approved 10 therapy visits. It is not clear at this time, without completion of the initial approved 10 visits, that 
the patient requires the unique skills of a professional therapist to safely and effectively provide treatment, or 
that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist beyond the therapy that was approved. The requested services are not part of a maintenance program, 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six (6) physical therapy visits.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the patient can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for osteomyelitis and gangrene of the lower extremity and had a below the knee amputation. The 
patient's medical problems are stable and there are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve braces (D8040). 
 
You asked the Plan to pre-approve braces. You say that your provider recommended this treatment. The Plan 
denied your request. The Plan says this service is not covered under your benefit plan. 
 
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 pre-approve 
braces (D8040).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Osteocel Allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says they have utilized a review of the medical literature which notes that 
Osteocel allograft remains experimental for use in spinal surgery as a bone graft as the Iliac crest is the gold 
standard. The Plan states the clinical value and effectiveness of Nuvasive Osteocel allograft in the setting of 
lumbar surgery have not been demonstrated in the peer-reviewed literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found iliac crest remains the gold standard.  Osteocel allograft is experimental as more quality research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nuvasive Osteocel Allograft (CPT code 20930).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a magnetic resonance 
imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no network providers 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a magnetic resonance imaging (MRI) of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgery to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the request for payment at the in-network benefit level for the 
requested out-of-network provider remains upheld. The Plan states there are in-network providers that can 
provide the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the surgery to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious disease (bacterial or viral respiratory tract DNA or 
RNA, 22 targets (0202U). 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting a medical necessity 
review for the denied services, reconsideration of the denial, review of the medical records and approval of the 
services provided. The Plan denied your request. The Plan says Medicare says screening panels for respiratory 
symptoms are not a benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. 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 infectious disease (bacterial or viral respiratory tract DNA or RNA, 22 targets (0202U).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient hematology/oncology treatment with an out-
of-network provider. 
 
You asked the Plan to pre-approve specialist services. You say that you have been treated by this provider for 4 
years and need to continue care with him. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be 
treated by an in-network hematology/oncology specialist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 specialist services. Our reviewer says 
that you do not meet the Medicare criteria for continuity of care with this out-of-network provider. Our 
physician reviewer found you are on observation and are not currently receiving any active treatment and/or 
management of your condition that would make it medically necessary to continue care with the out-of-
network hematology/oncology specialist. There is not anything unique about your condition that would make it 
necessary to continue care with an out-of-network specialist. Your condition is treated by most oncologists. 
The Plan has in-network hematology/oncology specialists who have the qualifications and expertise necessary 
to meet the current medical Standards of Care required for treatment of your condition. Your medical 
management can be safely transitioned to an in-network provider at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of specialist services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve outpatient hematology/oncology treatment with an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound rendered on December 14, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the plan paid zero for the breast 
ultrasound. The Plan denied your request. The Plan says the copayment applied 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 a $160 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.  
 
 You have been asked to pay $80.32 for the ultrasound, which is less than the $160 copayment for this category. 
The ultrasound falls 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 copayment for the ultrasound rendered on December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from August 31, 2021, to September 2, 2021. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation services. You say that you were moved 
to a new room by the bed rolling down the hall, and from your perspective you were simply being moved to a 
different room in the same hospital. You also say that you that if you had been properly notified of the $350 a 
day charge, you would have requested to be discharged on August 31, 2021. The Plan denied your request. The 
Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day for days 1 to 5 for inpatient hospital care.  
 You have been asked to pay a $350 copayment per days for 2 days of inpatient rehabilitation services, which is 
a total of $700 ($350 x 2 = $700). Inpatient rehabilitation services fall within the inpatient hospital 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 inpatient rehabilitation services provided from 
August 31, 2021, to September 2, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Peripheral Nerve Stimulation (PNS) procedure. 
 
You asked the Plan to pre-approve a PNS procedure. You say that you suffer from chronic pain symptoms of 
the bilateral back and you have tried conventional treatment including physical therapy, chiropractic care, 
TENS therapy, nerve blocks and sacroiliac joint injections, however your pain and functional limitations 
persist. You say that you have not sustained long term benefit from NSAIDS, muscle relaxers, and neuropathic 
medication and the pain limits activities of daily living. The Plan denied your request. The Plan says the current 
peer-reviewed data does not support PNS for fibromyalgia, phantom limb pain, and diffuse polyneuropathy, 
nociceptive pain in trunk or lower back, or angina pectoris. Claims for these indications will be denied as not 
reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that current peer-reviewed data does not support PNS for 
fibromyalgia, phantom limb pain, diffuse polyneuropathy, nociceptive pain in trunk or lower back, or angina 
pectoris. Claims for these indications will be denied as not reasonable and 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 PNS procedure. Our reviewer says that 
PNS is not medically reasonable and necessary. Our physician reviewer found that there is not enough clinical 
evidence to support the use of a peripheral nerve stimulator for low back pain. The request is deemed not 
medically reasonable or 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 PNS procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PNS procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Eliquis tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Eliquis 
tablet.  
 Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
23, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 23, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cologuard colorectal screening test provided on June 1, 
2021. 
 
You asked the Plan to pay for the Cologuard colorectal screening test. You say that this procedure was 
medically necessary for screening purposes and should be reprocessed and approved for payment. The Plan 
denied your request. The Plan says the benefit has previously been exhausted and no payment is due. 
 
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered once every three 
years.   
We looked at the file and Medicare rules. In this case, the Cologuard test was administered previously in 2019. 
Three years had not passed since the service was received on June 1, 2021. Based on this information, we 
decided that Medicare rules for coverage of the Cologuard colorectal screening test have not been met. 
Therefore, we decided that the Plan does not have to pay for the Cologuard colorectal screening test provided 
on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on September 9, 2021. 
 
You asked the Plan to pay for the services provided. You say that the procedure was rendered in the 
appropriate place of service. The Plan denied your request. The Plan says the rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 85060 is Blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We looked at the file and the rules. We find that payment for CPT code 85060 may be made only if the 
physician interprets an abnormal smear for hospital inpatient. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the pathology services provided on September 9, 2021.