Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy services provided on November 19, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for chemotherapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chemotherapy services provided on November 19, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on November 18, 2021. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says routine vision 
services are offered through the Plan Vision Care. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when received by a participating provider. 
 We looked at the file and the Plan's rules. The file shows that the eyeglasses were not received by a 
participating provider. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided 
on November 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for cardiac rehabilitation and
lab services provided from June 2, 2021, to August 16, 2021.
You asked the Plan to waive or reduce any of this cost share. You say that you do not believe this cost share is
correct. The Plan denied your request. The Plan says each cost share was charged based on the services
provided and the Plan contract agreement. Maximus partially overturned the Plans denial because the case file
lacked the August Explanation of benefits. The Plan requested a reopen and provided a copy of the August
Explanation of benefits showing the required $40 copayment. This was $30 for the cardiac rehabilitation visit
and $10 for lab services.
The Plan is correct in this case. 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 cost share for each cardiac rehabilitation and lab visit.
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 or reduce the cost share charged for cardiac rehabilitation and lab services provided
from June 2, 2021, to August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330), four surgical extractions 
(D7210 x4), and alveoloplasty in conjunction with extractions (D7310) provided on January 18, 2022. 
 
You asked the Plan to pay for the panoramic x-ray, surgical extractions, and alveoloplasty. The Plan denied 
your request. The Plan says these services are not covered under the base dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330), four surgical extractions (D7210 x4), and alveoloplasty in conjunction with 
extractions (D7310) provided on January 18, 2022.
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 transfer to an LTACH was medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus
overturned the Plans denial for lack of medical records in the file. The Plan requested a reopen and provided
the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for long term acute
care hospital (LTACH) services. The medical records show you had a medical history of heart disease,
hypertension, left nephrectomy, and chronic kidney disease. The enrollee was admitted to the acute care
hospital on 9/17/21 with acute hypoxic respiratory failure, Covid-19 pneumonia, and acute kidney injury.
Intubation and subsequent tracheostomy were required. A PEG tube was placed. Hemodialysis was
administered from October 13, 2021, through October 25, 2021. On November 29, 2021, the records show you
had "fairly significant respiratory distress and green-tinged sputum." Per report, you had started to follow some
simple commands.
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not
provide clinical services that are materially different than those of short-term acute care hospitals.
You were receiving acute hospital care, and acute care services had not been denied. The documentation does
not support that the enrollee in this case required services at the LTACH that were not available at the acute
care hospital where she was then receiving care. Consequently, the requested LTACH services were not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at the 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 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 71260. We decided that the Plan does not have to pay 
for procedure codes G0463 and G1004.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan says that the 
services were not billed correctly. 
 
We decided that the Plan has to pay for the CT scan of the thorax billed with code 71260. 
 
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 not provided a valid denial reason for procedure code 71260. The 
denial states that this code has an OPPS status indicator of S and APC payment of 5571, and while this is 
correct, the status indicator of and APC payment are allowable as billed. The Plan has not provided any binding 
Medicare rules or documentation to support that code 71260 is not payable as billed. Therefore, we decided 
that the Plan has to pay for the computed tomography (CT) scan of the thorax rendered on October 25, 2021. 
 
We also decided that the Plan does not have to pay for the outpatient clinic visit and clinical decision 
support mechanism billed with codes G0463 and G1004. 
 
The rules say that an OPPS payment status indicator is assigned to every HCPCS code. 
 
Billed procedure code G0463 has an OPPS status indicator of V when billed for a clinic visit and is not payable 
under Medicare in this setting. Code G1004 has an OPPS status indicator of E1 and is not payable in the 
outpatient clinic setting. Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit 
and clinical decision support mechanism rendered on October 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the services have been requested from an out-of-network provider. 
 
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $140 cost-sharing for x-ray, injection/surgical
supplies, and office visit services (77002, 64450, A9577) provided on June 15, 2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share to be
correct. The Plan denied your request. The Plan says this cost share was applied based on the claim submitted
by your provider and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan
requested a reopen and stated Maximus did not apply the Plan contract appropriately.
The Plan says that they administratively upheld the post-service appeal for the copayment of codes 77002 (xray
services) and 64450 (injection of anesthetic agent and/or steroid into other peripheral nerve or branch) and
the coinsurance for code A9577 (Injection Gadobenate Dimeglumine multihance Per ml).
Per the 2021 Evidence of Coverage, page 4-33 in Chapter 4: $110 copayment for Medicare-covered
radiological diagnostic services, not including X-rays, performed in a physician's office or at a freestanding
facility (such as a radiology center or medical clinic). You pay these amounts until you reach the out-of-pocket
maximum. Your provider may need to obtain prior authorization. The diagnostic radiology services require
specialized equipment beyond standard X-ray equipment and must be performed by specially trained or
certified personnel. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA,
nuclear studies, ultrasounds, diagnostic mammograms, and interventional radiological procedures (myelogram,
cystogram, angiogram, and barium studies). The provider billed procedure code 77002 in the amount of
$199.00. The allowed amount for procedure code 77002 is $111.58. As stated in the above guidelines, the
member was assessed the correct cost share as the service of code 77002 is considered a diagnostic radiology
service which is beyond the standard X-ray and was performed by a specialized trained and certified personnel.
Per the Plan contract and Medicare rules, the Radiological diagnostic services applied correctly.
The Plan is correct in this case. 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 $110 for outpatient diagnostic services such as those provided to you in this
appeal and a $30 copayment for physician visits. 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 or reduce waive the cost-sharing for x-ray,
injection/surgical supplies, and office visit services (77002, 64450, A9577) provided on June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denila. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
unspecified hypercalcemia. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. The Prolia is 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 Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the closed treatment of distal radial fracture (25605) 
provided on August 25, 2021. 
 
You asked the Plan to pay for the closed treatment of distal radial fracture (25605). You say that the notes 
should be reviewed and payment for surgery reconsidered. The Plan denied your request. The Plan says 
procedure code 99283 has been overturned and procedure code 25605 is not supported by the medical records 
submitted. 
 
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, the CPT Code Manual definition of code 25605 is closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed; with manipulation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the closed treatment of distal radial fracture (25605). Our 
reviewer says that that the documentation submitted was reviewed and does not meet the criteria for coverage. 
Our reviewer found the procedure report does not include documentation of closed treatment of distal radial 
fracture or epiphyseal separation with manipulation. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the closed treatment of distal radial fracture (25605) have not been met. 
Therefore, we decided that the Plan does not have to pay for the closed treatment of distal radial fracture 
(25605) provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is unable to walk due to a 
stroke and above-knee amputation. The Plan denied your request. The Plan says the enrollee is not able to 
operate the power wheelchair safely. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device is only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a Group 3 qualifying diagnosis of a neurological condition. The 
documentation indicates she has a mobility deficit that impairs MRADLs in the home. The documentation does 
not reveal an objective detailed physician exam of the upper and lower extremities or detailed neurologic exam.  
There are no objective physician exam findings of strength, endurance, range of motion, or coordination, 
presence of pain, or deformity or absence of both upper and lower extremities that support that she cannot use 
an optimally configured manual wheelchair. The documentation states that the current manual wheelchair is no 
longer providing adequate positioning. It is unclear whether an optimally configured manual wheelchair can be 
used. Additionally, the neurologic exam is not clear that she can adequately and safely operate a power 
wheelchair. Therefore, the requested wheelchair is not medically reasonable or necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair and related accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 surgical extractions (D7210 x3) or pay more for the one 
surgical extraction (D7210) provided on December 10, 2021. 
 
You asked the Plan to pay for the three surgical extractions and to pay more for the one surgical extraction. 
You say that you are retired and on a fixed income. The Plan denied your request. The Plan says your 
maximum dental benefit has been exhausted. 
 
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 Plan will cover up to $200 for any 
dental services that are not covered in the preventive services section. The record shows that you received four 
surgical extractions on December 10, 2021, the Plan paid $200 for one of these extractions, and your annual 
maximum dental benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 3 
surgical extractions (D7210 x3) or pay more for the one surgical extraction (D7210) provided on December 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0289) provided on September 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 G0289 
is a column II code to column I code 29880. 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 the services (G0289) provided on September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service August 19, 
2021. 
 
You asked the Plan to pay for procedure code 20930. You say that you believe that this code is separately 
payable. The Plan denied your request. The Plan says no separate payment is made for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 20930 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 20930 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 20930 billed for date of service August 19, 2021.