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

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says a SNF admission is not medically necessary. 
 
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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that you have stabilized 
medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled 
therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. 
You are medically stable without any acute exacerbations of chronic medical problems. Your physical function 
is at or near her baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient 
skilled rehabilitation services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve liposuction (surgical removal) of the upper back/neck 
area. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says cosmetic procedures are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery. Our reviewer says that the 
requested procedure is not medically reasonable or necessary. Our reviewer found the records indicate that the 
enrollee has a Buffalo Hump. The record indicates treatment was sought for appearance purposes and the 
provider indicated that the issue is cosmetic in nature. 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve liposuction (surgical removal) of the upper back/neck area.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you received 
on June 14, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you should not have to pay for the ECG 
because it is standard care for your condition. The Plan denied your request. The Plan says you were charged 
this copayment correctly.  The Plan says that because the allowed amount for this service ($14.55) is less than 
your copayment obligation, you are responsible for the full allowed amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for non-radiological diagnostic services.  
 
 You have been asked to pay a $20 copayment for the ECG. The ECG falls within the non-radiological 
diagnostic services benefit category. This copayment applies regardless of the necessity and appropriateness of 
the service. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you received 
on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from June 17, 2021, to July 23, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You did not provide an 
argument in your appeal request. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
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 $150 
copayment per day for days 1-7 and a $0 copayment for days 8-90 for inpatient hospital services.  
 
Records show you were in the hospital for 6 days.  You were charged a $150 copayment per day, for a total of $900. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for inpatient hospital services you received from 
June 17, 2021, to July 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthosis (L4396), provided on January 27, 2021. 
 
You asked the Plan to pay for the foot orthosis. You say that the service should be covered. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment when enrolled in hospice.
 
 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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the foot orthosis (L4396), provided on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel 
to home or nursing home services coded R0070 provided on June 3, 2021. 
 
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing 
home services. You say that you would like the plan to reconsider their denial. The Plan denied your request. 
The Plan says the services are not payable 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 R0070 is transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen. 
 
 We find that CPT code R0070 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee was in a hospital facility setting for this date of service. This means this code was billed with 
an inappropriate place of service for this procedure. Based on this information, we decided that Medicare rules 
for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home services 
have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable 
x-ray equipment and personnel to home or nursing home services coded R0070 provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740 x 4) and core build up (D2950 x 4) 
provided on July 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services you received relate to an accidental 
injury. You say that this resulted in breaking 2 teeth and 2 crowns. You also say that you are on a fixed income. 
The Plan denied your request. The Plan says the services you received are routine dental in nature. The Plan 
says that the crowns are not listed as covered services. The Plan says that core build up is not listed as a 
covered service. The Plan also says that you were not enrolled in the optional supplemental dental rider. 
 
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 crowns and core build up are not 
among those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve 
the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your 
teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the 
Plan does not have to pay for the crown (D2740 x 4) and core build up (D2950 x 4) provided on July 7, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pre-approve Transcutaneous Mitral Valve Replacement (TMVR) for
the enrollee.
You asked the Plan to pre-approve TMVR. You say that this procedure is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Transcutaneous
Mitral Valve Replacement (TMVR). The Maximus Physician Reviewer determined that the only feasible
treatment option for the enrollee was placement of a transcatheter mitral valve-in-valve, and that the procedure
was medically reasonable and necessary. The Plan states that the criteria in Medicare guidelines for
Transcatheter Mitral Valve Repair are not met in this case. Our Medical Director says that the medical records
show the enrollee is an 81-year-old man with severe bioprosthetic mitral valve stenosis. A transcatheter mitral
valve-in-valve replacement using a transseptal approach was recommended. The Plan denied coverage for the
TMVR procedure, stating that the device that the mitral valve would be replaced with is only approved for use
in the aortic valve. Our Medical Director has determined the Maximus Physician Reviewer was not correct in
this case. National Coverage Determination (NCD) 20.33 states that TMVR used for the treatment of any nonmitral
regurgitation indications are non-covered. The TMVR in this case was not used for mitral regurgitation
indication. Therefore, Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TMVR have not been met. Therefore, we decided that the Plan does not have to
pre-approve Transcutaneous Mitral Valve Replacement (TMVR) for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the intrauterine device (IUD) and placement rendered on May 5, 2020.
You asked the Plan to pay for these services. You say that the services were performed for treatment of pre-cancerous cells. The Plan denied your request. The Plan says that the services are not a covered benefit.
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 states that the services are not covered by Medicare. While the rules state that an IUD is not covered as a preventive contraceptive device, the file shows that the services were rendered for a medical diagnosis of endometrial hyperplasia with atypia, not for contraception. Therefore, we decided that the Plan has to pay for the intrauterine device (IUD) and placement rendered on May 5, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan does not have to waive or reduce the cost share applied to the yearly deductible for
podiatry services provided on May 22, 2020.
You asked the Plan to waive or reduce this cost share. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says the contract is clear that podiatry services apply to the
deductible. The QIC partially overturned the Plans denial. The Plan requested a reopen and stated that
the QIC did not apply the correct contract language.
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. Your 2020 contract with the Plan says that there was a $750 deductible. The Plan
contract also shows the deductible requirement under podiatry services. The medical records show you saw a
podiatrist who provided treatment for your nails. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is $750 for deductible. This cost sharing is a contractual obligation that had not been met
at the time of service. Therefore, we decided that the Plan does not have to waive or reduce the cost share
applied to the yearly deductible for podiatry services provided on May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on May 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the bloodwork was collected from the 
provider/facility and was unable to be processed by an in-network laboratory. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the services was referred by an out-of-network provider. Therefore, we decided that the Plan 
does not have to pay for the pathology services provided on May 18, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on 
June 28, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network medical services provided to the 
enrollee on June 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 28, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue 
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an 
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound you had at an 
outpatient hospital facility on July 23, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you called the plan and you were 
told your copayment was only $15. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan says that there are no records of you calling the Plan prior to the date of service 
asking about cost sharing for diagnostic tests and procedures.  There was a call from the facility on July 22, 
2021, and the facility was advised of the $50 copayment for this service. 
 
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 $50 
copayment for ultrasounds in an outpatient hospital setting.  
 You have been asked to pay a $50 copayment for the ultrasound. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the abdominal ultrasound you had at an outpatient hospital facility on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Freestyle Libre sensors (K0553) provided on June 9, 2021. 
 
You asked the Plan to pay for Freestyle Libre sensors. You say that the requested items are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for continuous glucose monitor 
supplies have not been met.  
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assess 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The provided documentation is insufficient to indicate whether the 
enrollee sperform blood glucose testing at least four times per day. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre sensors have not been met. Therefore, we decided that the Plan 
does not have to pay for Freestyle Libre sensors (K0553) provided on June 9, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78816).
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan denied your request. The Plan says that rules for coverage have not been met.
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 the PET scan. Our reviewer says that the PET scan is medically necessary. Our physician reviewer found a PET scan is indicated for men with suspected prostate cancer recurrence based on elevated PSA tests following prior treatment. 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78816).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diagnostic shoulder arthroscopy (29805). 
 
You asked the Plan to pre-approve the diagnostic shoulder arthroscopy. You say that you would like 
reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan 
says the request for the diagnostic examination of shoulder using an endoscope is denied as unbundling and 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 the diagnostic shoulder arthroscopy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation is not evident regarding any indication for 
separate billing of a diagnostic procedure when there is already diagnostic evidence of pathology. In addition, this request would be typically included with the approved procedure, and not billable separately. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 diagnostic shoulder arthroscopy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the diagnostic shoulder arthroscopy (29805).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on February 17, 2021.