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

 
We decided that the Plan does not have to pay for procedure code 72080 billed for date of service May 26, 
2022. 
  You asked the Plan to pay for procedure code 72080. You say that there is no conflict with the codes if the 
documentation supports the procedures are separate. The Plan denied your request. The Plan says payment for 
code 72080 is bundled into payment for code 72070. 
 
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 72080 
is a column II code to column I code 72070. 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 72080 billed for date of service May 26, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the medication will further combat the enrollees 
current diagnosis. The Plan denied your request. The Plan says the enrollee has not tried and failed Retacrit or 
Procrit. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our physician reviewer found 
that the enrollee has anemia of chronic kidney disease. The requested medication is a new start. The Plan 
requires a trial of Retacrit or Procrit before they will approve the requested drug. The provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternative.  The elements of the coverage criteria are not satisfied.  Therefore, the requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the initial hospital care (99222) and 
subsequent hospital care (99233) provided on May 5, 2022, and May 6, 2022. 
 
You asked the Plan to waive the deductible for the hospital care. You say that while you were in the hospital, a 
kidney doctor came to see you and advised you should see them. You also say that they only gave you a 
business card, and did not provide any services for you. The Plan denied your request. The Plan says the 
deductible amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $200 deductible for in-network services which applies to inpatient 
hospital care.  
 
The item or service you asked the Plan to waive the deductible for falls within the Inpatient Hospital Care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 
deductible for in-network services which applies to inpatient hospital care. This cost sharing is a contractual 
obligation that had not been met at the time the hospital care was received on May 5, 2022 to May 6, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the initial hospital care (99222) 
and subsequent hospital care (99233) provided on May 5, 2022, and May 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Novolog. 
 
You asked the Plan to pre-approve a tier exception. You say that you are on a fixed income and cannot pay the 
amount. The Plan denied your request. The Plan says tier exceptions are not available for Part B drugs. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
The requested drug falls within the Medicare Part B prescription drugs benefit category. This means that a 20% 
coinsurance is 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 pre-approve a tier exception for Novolog.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral neurostimulator pulse generator. 
 
You asked the Plan to pre-approve peripheral neurostimulator pulse generator. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for this procedure. 
 The Plan follows Medicare rules. Medicare rules state that nerve stimulation for urinary incontinence is only 
covered if certain 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 peripheral neurostimulator pulse 
generator. Our reviewer says that the enrollee does not meet the Medicare criteria for use of this pulse 
generator. Our physician reviewer found the enrollee has not demonstrated adequate ability to record voiding 
diary data such that clinical results of the implant procedure can be properly evaluated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral neurostimulator pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a peripheral neurostimulator pulse generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 18, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were referred to an 
oral surgeon because you broke a tooth that could not be extracted by your dentist. The Plan denied your 
request. The Plan says your benefit for the service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service April 19, 2022. Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on 
May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the blood smear interpretation (85060) provided on April 13, 
2022. 
 
You asked the Plan to pay for the blood smear interpretation (85060). You say that the procedure was rendered 
in the appropriate place of service and the claim should be reconsidered for payment. The Plan denied your 
request. The Plan says CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital 
patients. 
 
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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
  We find that CPT code 85060 is not supported in the medical record. Specifically, procedure code 85060 has 
an indicator of 8. This means that payment cannot be issued when furnished to hospital outpatients or non-
hospital patients. Based on this information, we decided that Medicare rules for coverage of the blood smear 
interpretation (85060) have not been met. Therefore, we decided that the Plan does not have to pay for the 
blood smear interpretation (85060) provided on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic cushion (E1399). 
 
You asked the Plan to pre-approve the orthopedic cushion. You say that this item is medically necessary. The 
Plan denied your request. The Plan says the requested item is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic cushion (E1399).
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 this member has had a severe decline in function 
following acute hospitalization. You also say that the member will benefit from three hours daily of inpatient 
rehabilitation to help return to the highest level of function. The Plan denied your request. The Plan says the 
member does not meet the Medicare criteria for admission to an IRF. 
 
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 there are no rehabilitation nursing needs. Our physician reviewer also found that 
while the enrollee may benefit from continued physical and occupational therapy, the enrollee's rehabilitation 
needs can be safely provided in a lower intensity and alternate setting such as in a skilled nursing facility 
(SNF). 
 
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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for an office visit. We decided that the Plan does not 
have to waive the copayment for an office visit.  
 
You asked the Plan to waive the copayment for an office visit. You say that this physician is not a specialist. 
The Plan says that the copayment applied was correct. 
 
We decided that the Plan has to reduce the copayment for an office visit.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $15 copayment for each in-network primary care 
physician's office visit.  
 
The Plan says you must pay a $25 copayment for a specialist office visit. Based on the Plan contract, however, 
you cannot be asked to pay more than a $15 copayment for a primary care physicians office visit. The 
physician who performed the service is not a specialist. Therefore, we decided that the Plan has to reduce the 
copayment for an office visit provided on March 7, 2022. 
 
We also decided that the Plan does not have to waive the copayment for an office visit. 
 
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 $15 
copayment for a primary care physicians office visit. Therefore, we decided that the Plan does not have to 
waive the copayment for an office visit. 
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review. 
 
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. 
 
Your complaint about your doctors attitude and issues completing a referral is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove transportation ancillary: parking fees, tolls (A0170). 
 
You asked the Plan to preapprove transportation ancillary: parking fees, tolls (A0170). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says your benefit only allows 60 
one-way trips, whereas each one-way trip must not exceed 50 miles. The Plan also says that this request is not 
covered by the Plan. 
 
 
 
 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 one way ground transportation trips per year, and each trip must not 
exceed 50 miles of driving distance. 
 
We looked at your request, the records in the case file, and the rules. The requested trips are 57 total miles, 
which is more than the exceeded amount. 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 preapprove transportation ancillary: parking fees, tolls (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard, power wheelchair (K0800x13) and a 
power wheelchair accessory, U-1 sealed lead acid battery (E2365x26). 
 
You asked the Plan to pre-approve a power wheelchair and accessory. You say that the requested wheelchair is 
medically necessary. The Plan denied your request. The Plan says you can ambulate 200 feet before needing to 
sit down, and you are able to perform MRADLs in the home. The Plan also says you have sufficient strength to 
self-propel a manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 1 standard, power wheelchair (K0800x13) and a power wheelchair accessory, U-1 sealed lead acid 
battery (E2365x26).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on October 4, 
2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like payment to be 
reconsidered for the services performed. The Plan denied your request. The Plan says the enrollee was enrolled 
in hospice on this date of service, and traditional Medicare is the primary payer when in hospice care. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on October 4, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
code 74174. 
 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 74176 
is a column II code to column I code 74174. 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 74176 billed for date of service April 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to a SNF 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lokelma. 
 
You asked the Plan to pre-approve Lokelma. You say that the enrollee's potassium is not controlled by diet. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under 
Medicare 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 pre-approve Lokelma.  
 
 Benefits for Lokelma 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 pre-approve a computerized tomography (CT) scan of the lower 
extremity without contract. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records submitted do not show an examination of the 
enrollee's knee was performed by the physician; therefore, the CT scan cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that that 
the CT scan of the lower extremity without contract is not medically needed at this time. Our physician 
reviewer found that in this case, the record indicates that the enrollee has a knee effusion. The record does not 
indicate any traumatic event or the results of any physical examination or plain films. The provided records do 
not indicate that conservative treatments have been tried and failed and do not document the presence of any 
red flag symptoms or events. The provided records do not indicate the medical necessity or reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) scan of the lower extremity without contract.