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

 
We decided that the Plan does not have to pre-approve 9 additional miles for routine transportation. 
 
You asked the Plan to pre-approve 9 additional miles for routine transportation. You say that you were referred 
to this group because they specialize in your diagnosis, and you have been a patient of theirs for the last two 
years. You also say that you cannot legally drive yourself, were unable to find another means of transportation, 
and need your medications renewed. The Plan denied your request. The Plan says this service is covered under 
your benefit package, but exceeds the maximum count allowed per period. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 9 additional miles for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fistulogram to be provided at an out-of-network 
tertiary care center. 
 
You asked the Plan to pre-approve the outpatient service. You say that where your device was put in is 
completely gone and swollen. You say that it has been swollen for over 2 months. You say that you need to see 
this provider because they are the one that did the surgery. You also say that it is their obligation to fix this. 
The Plan denied your request. The Plan says the requested service can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 provider at issue in this case is not a network provider with the Plan. 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 outpatient service. Our reviewer says that it is not medically necessary 
for this service to be performed an out-of-network tertiary care facility. Our physician reviewer found the 
provided records do not document anything unique about your history or condition which necessitates performing the fistulogram by an out-of-network tertiary care center as opposed to care from an in-network 
provider. Therefore, the reviewer found that it is not medically necessary for this service to be performed an 
out-of-network tertiary care facility. 
 
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 outpatient service have not been met.  
 
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 the outpatient service. Therefore, we decided that the 
Plan does not have to pre-approve a fistulogram to be provided at an out-of-network tertiary care center.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 47490 billed for date of service January 16, 2022. 
 
You asked the Plan to pay for procedure code 47490. You say that this service was medically necessary and 
was billed appropriately. The Plan denied your request. The Plan says that the payment for this service is 
included in the global surgery package of procedure code 47531, which was billed for date of service January 
24, 2022. 
 
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. Specifically, the Plan argues that this service is included in the global surgery 
package for another code which was billed on another date, but the file sent to us does not include any claim 
documentation or evidence of this other service which would include code 47490 in the global surgery 
package. Therefore, we decided that the Plan has to pay for procedure code 47490 billed for date of service 
January 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to LTACH is medically 
necessary and will help the enrollee recover fully. The Plan denied your request. The Plan says the enrollee can 
safely receive care in another setting, such as Skilled Nursing Facility (SNF) or at home with home health 
services or outpatient setting if appropriate. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the 
abdominal aorta and both legs. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you are a former 
smoker with a history of bacterial infection (cellulitis) and a slowly-healing wound on the right leg. Duplex 
ultrasound and ankle arm indices were performed. The ankle brachial indices (ABIs) were normal. The records 
do not contain specific rationale to support the use of the requested CTA scans. The services are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography angiography (CTA) of the abdominal aorta and both legs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom prosthetic partial hand and finger prosthesis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be covered as the incorrect code is used. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the custom bilateral partial hand with Naked Prosthetic Grip Lock for fingers 4 on the right, Naked 
Prosthetic MCP Drivers for fingers 3-4 on the left exceed the patient's medical need and are not medically 
necessary. There is a lack of high-quality evidence in the literature of functional outcomes for partial hand 
prosthesis with the requested body powered Naked prosthetics. Additionally, a review of the specifications 
reveals that the items exceed the patient's functional needs. Per the Naked Prosthetics Product Technical 
Specifications, the prosthetics are designed to get workers back to difficult jobs, and for people who use their 
hands in harsh environments. All products are resistant to most common chemicals such as isopropanol, 
ethanol, acetone, and oil, as well as water, dust and dirt. The prosthetics come in multiple color options as well. These features exceed the patient's medical and functional need and do not meet the criteria for medical 
necessity. 
 
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 a custom prosthetic partial hand and finger prosthesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on July 14, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 60-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation to weekly dialysis appointments. The Plan denied your request. The Plan says you have 
exhausted your transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that they have covered 60 trips. Based on this information, we decided that you have exhausted the 
Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional trips for routine transportation beyond the Plan's 60-trip limit.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete series dental x-ray provided on February 21, 2022, billed
with code D0210.
You asked the Plan to pay for the complete series dental x-ray. You say that you did not realize there was any
limitation for this benefit. The Plan denied your request. The Plan says that your benefit for the requested item
or service has already been exhausted.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to
deny your request. There is no evidence showing your benefit for the requested item or service was previously
exhausted. The Plan provided proof that you received a complete series dental x-ray on June 5, 2019. You
received your complete series dental x-ray on February 21, 2022, which is outside of three plan years from the
previous procedure. Therefore, we decided that the Plan has to pay for the complete series dental x-ray
provided on February 21, 2022, billed with code D0210.
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided on August 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the colonoscopy. You say that you were not advised that prior authorization was 
required for a screening colonoscopy. You say that the medical records provided support the medical necessity 
of the services in dispute. The Plan denied your request. The Plan says the services provided require prior 
authorization when performed by a non-contracted provider. The Plan says that no prior authorization was 
obtained. 
 
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 at issue in this case is not a network provider with the Plan.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the colonoscopy have not been met.  
 
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 pay for the colonoscopy provided OON. Therefore, we decided that 
the Plan does not have to pay for a colonoscopy provided on August 8, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. Usually, IGRT 
is used when critical structures are abutting or in close proximity to the target that is being treated to high 
doses. This situation does not apply to this patient for which the target lesion can be seen on the skin to assist in 
daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being 
treated. Certainly using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore to 
bill for daily simple simulations and/or IGRT for a technology for which need has not been established by 
published data or supported by consensus guidelines (many of which recommend against treatment with these 
devices in general- citations below) is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided radiation therapy (US-IGRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute 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 that the coverage criteria has not been met. 
 
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 that you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
the safety and effectiveness of the procedure. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided to the enrollee on December 16, 2021.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says this claim was submitted with errors preventing payment. Maximus
overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and
provided additional information. The Plan provided documentation to show that Medicare guidance says the
term Medicare Beneficiary Identifier (MBI) is a general term describing a beneficiary's Medicare identification
number. The MBI references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary
Identifier (MBI) during the new Medicare card transition period and after for certain business areas that
will continue to use the HICN as part of their processes. The electronic form required for billing ESRD claims
is the ASC X12 837 institutional claim transaction. The paper form, where permissible, is Form CMS-1450.
The coding and related descriptions for the following items are identical for the ASC X12 837 institutional
claim format and Form CMS-1450. The Plan is upholding the denial because the claim was not submitted with
the appropriate condition codes required for the billed date of service.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes.
In this case, the claim submitted has data element errors preventing payment. The Plan states a corrected claim
would be reviewed if submitted. Medicare rules for coverage of this claim have not been met. Therefore, we
decided that the Plan does not have to pay for medical services provided to the enrollee on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection. 
 
You asked the Plan to pre-approve epidural steroid injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 epidural steroid injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation does not 
reveal objective physical examination supporting the need for an interlaminar epidural injection in the L5-S1 
region. The documentation does not reveal objective evidence of failure of four weeks of noninvasive 
conservative care for the lumbar spine or acute herpes zoster refractory to conservative management. The 
November 18, 2022 progress note indicates normal bilateral lower extremity sensation, motor function and no 
signs suggestive of a lumbar radiculopathy in the proposed injection area. LCD L39036 criteria have not been 
met for a lumbar epidural steroid injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injection.