Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided in the Republic of Lebanon from 
November 2, 2021, to November 3, 2021. 
 
You asked the Plan to pay for hospital care. You say that you fell and this surgery was needed as an 
emergency. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the necessary documentation was not provided to support payment of this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not typically cover services 
performed outside of the United States. The Plan offers a worldwide coverage supplement that goes beyond 
Medicare coverage. For that reason, the Plans rules apply to this case. The Plan covers up to $100,000 for 
emergency, urgent care, and emergency transportation received outside of the United States. You must first pay 
for medical care received, and submit a discharge summary or equivalent medical documentation and proof of 
payment. 
 
We looked at the file and Medicare rules. You did not submit a discharge summary or equivalent medical 
documentation for review. Without this documentation, your request does not meet the Plans criteria for 
coverage. Therefore, we decided that the Plan does not have to pay for hospital care provided in the Republic 
of Lebanon from November 2, 2021, to November 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 
11, 2022, to May 13, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee should not have to 
pay due to inadequate care. The Plan denied your request. The Plan says the enrollee has been 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $395 per day for days 1-4 and $0 per day after day 4 for each inpatient stay.  
 
The file shows that the enrollee was in the hospital for two full days from May 11, 2022, to May 13, 2022. The 
enrollee has only been asked to pay $395 per day for one day of inpatient care. The inpatient care falls within 
the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided from May 11, 2022, to May 13, 2022.
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 you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 document does not support the medical necessity for admission to 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Medicare covered CT scan provided on 
January 6, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were not aware of the high 
copayment. The Plan denied your request. The Plan says the copayment applied was 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 $350 
copayment for Medicare covered CT scans.  
 
You have been asked to pay a $350 copayment for a CT scan. A CT scan falls within the Outpatient Diagnostic 
Tests 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 a Medicare covered CT scan provided on January 6, 2022. 
 Your complaint about not being informed about the copayment rate 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair and supplies (K0739, K0108, E0967) provided 
on January 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wheelchair and supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they were 
non-emergent and provided by 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 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 a wheelchair and supplies (K0739, K0108, E0967) 
provided on January 31, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS device is 
medically necessary for this enrollee due to the ability to medically manage this particular enrollee's heart 
failure to prevent myocardial injury and hospitalizations. The Plan denied your request. The Plan says the 
services are considered experimental and 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 the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on March 10, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the hospice facility has denied. You also 
say that the enrollee's plan is responsible for this payment. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 8, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided on March 
10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision care provided on February 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the vision care. You say that the provider is trying to be credentialed as in-
network. The Plan denied your request. The Plan says 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
vision care. We found no exception that would require the Plan to pay for the vision care. The records provided 
for review do not show that the vision care was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the vision care provided on February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three units of intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention (37253) billed for date of service November 23, 
2021. 
 
You asked the Plan to pay for three units of 37253. You say that these services were reported appropriately and 
are supported in the record. The Plan denied your request. The Plan says these services are not supported as 
billed. 
 
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 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each addition noncoronary vessel (List separately in addition to code for primary procedure). 
 
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 three units of 37253. Our reviewer says that three units of 
37253 are not supported in the medical record. Our reviewer found the operative report does not describe the intravascular ultrasound performed. This procedure cannot be cited in the report, as it was not documented. In 
addition, three units are not supported in the medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of three units of 37253 have not been met. Therefore, we decided that the Plan 
does not have to pay for three units of intravascular ultrasound (noncoronary vessel) during diagnostic 
evaluation and/or therapeutic intervention (37253) billed for date of service November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for extractions and implants for teeth numbers 22
and 27 (D7140 and D6010) for the enrollee.
You asked the Plan to provide coverage for these services. You say that these dental services are medically
necessary. The Plan denied your request. The Plan says dental implants are not covered and these teeth already
show being extracted November 26, 2021. Maximus partially overturned the Plans denial stating the case file
lacked documentation of the previous extraction. The Plan requested a reopen and provided documentation to
show the extractions were performed on November 26, 2021, for teeth numbers 22 and 27.
The Plan is correct in this case. Medicare generally does not cover dental services. 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 more than Medicare coverage, implants are not covered, and the dental records
show teeth numbers 22 and 27 were previously extracted. Therefore, we decided that the Plan does not have to
provide coverage for extractions and implants for teeth numbers 22 and 27 (D7140 and D6010) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopathic medicine services provided from  
February 11, 2022, to February 17, 2022. 
 
You asked the Plan to pay for naturopathic medicine services. The Plan denied your request. The Plan says 
naturopathic medicine services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturopathic medicine services provided from February 11, 2022, to February 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET/CT scan of the skull base to mid-thigh. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET/CT scan of the skull base to mid-
thigh. Our reviewer says that a PET/CT scan of the skull base to mid-thigh is not reasonable and necessary. Our 
physician reviewer found no repeat biopsy confirmed cancer was present to justify the PET at this point. Our 
reviewer also found that the enrollee does not have an indication for which a PET scan can be covered, and it 
will be considered not medically 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 a PET/CT scan of the skull base to mid-thigh have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base 
to mid-thigh (78815).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on November 16, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 10, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on 
November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on September 
15, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that if the services were performed 
correctly the first time on September 8, 2021, you would not have had to go back to get them done again. The 
Plan denied your request. The Plan says the coinsurance 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 $100 
copayment for outpatient surgery at an outpatient hospital facility or ambulatory surgical center.  
 
You have been asked to pay $100 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Hospital Services benefit category. The Plan has reprocessed the claims for the x-rays provided on 
September 8, 2021, and September 15, 2021, the assessed copayment is now $0. 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 outpatient surgery provided on 
September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammography (71250) provided on 
April 8, 2021. 
 
You asked the Plan to waive the copayment for the mammography. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $125 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $125 copayment for the mammography. Mammographys fall 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 a mammography (71250) provided on April 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 2, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient mental health services provided on 
March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laminectomy procedure (63277) and microsurgical 
techniques (69990) provided on February 17, 2022. 
 
You asked the Plan to pay for surgical services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because code 63277 
is inclusive to code 63047 and the record does not support code 69990. 
 
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 63277 is laminectomy for biopsy/excision of intraspinal 
neoplasm; extradural, lumbar. The CPT Code Manual definition of code 69990 is microsurgical techniques, 
requiring use of operating microscope. 
 
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 surgical services. Our reviewer says that these codes do not meet the criteria for payment. Our reviewer found the procedure report documents a laminectomy performed at 
L5 in addition to biopsy/excision biopsy at the same level. In this case, procedure code 63277 would be 
inclusive to code 63047 performed at the same level. The medical record does not include documentation to 
confirm procedures performed through operating microscope; therefore, procedure code 69990 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 surgical services have not been met. Therefore, we decided that the Plan does 
not have to pay for laminectomy procedure (63277) and microsurgical techniques (69990) provided on 
February 17, 2022.