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

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service May 16, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that this service is supported as billed. The 
Plan denied your request. The Plan says this service is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility visit provided on February 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility visit. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
  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 subsequent nursing facility visit provided on 
February 10, 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 intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of a lumbar radiculitis, lumbar spondylosis, lumbar post-laminectomy syndrome, and vertebrogenic low back 
pain have not been demonstrated in the peer-reviewed literature. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested intracept intraosseous 
basivertebral nerve ablation at L4 and L5 vertebral bodies, in this case, is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee and the 
enrollees anticipated discharged after IRF is to go home without any necessary services. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. 
The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve additional routine transportation services. 
 
You asked the Plan pre-approve additional transportation. You say that you need this service as you cannot 
drive, and this is the only way to get to your appointments. The Plan denied your request. The Plan says 
additional one-way routine trips cannot be approved. 
 
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 up-to 24 one-way routine transportation trips. We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, only 24 one-way 
routine trips are covered per year. Therefore, we decided that the Plan does not have pre-approve additional 
routine transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the Health Plan. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ILR. Our physician reviewer found 
there is insufficient documentation to support the medical necessity for insertion of an ILR in this enrollee's 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ILR (CPT code 33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on June 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that you are requesting reconsideration of the 
denial. You also say you would like the supporting records reviewed. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan, and the services were not referred by a network 
provider. The Plan also says that these services 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 wound care supplies provided on June 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for the 
enrollee's care. You also say that the enrollee meets the LTACH criteria for placement. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 
 
 
 
  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an oral appliance for the enrollee.
You asked the Plan to provide coverage for an oral appliance. You say that the requested oral appliance is medically necessary. The Plan denied your request. The Plan says all the required coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not follow the required Medicare criteria. The Plan states the medical records show no documentation of an in-person clinical evaluation by the treating physician prior to the sleep test to access obstructive sleep apnea testing.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare states all the required criteria in the LCD must be met for coverage of an oral appliance to be approved. The medical records provided do not show the enrollee meets all the required criteria regarding the evaluations needed for sleep testing and review for the appropriateness of an appliance. Medicare rules for coverage of an oral appliance have not been met. Therefore, we decided that the Plan does not have to provide coverage for an oral appliance for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 17, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not given any self-
administered drugs before or after the surgery. The Plan denied your request. The Plan says self-administered 
drugs are not a covered benefit while under an outpatient hospital stay. 
 
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 pay for the self-administered drugs 
provided on June 17, 2022.  
 
Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 test provided on February 7, 2022, by an OON 
provider. 
 
You asked the Plan to pay for a COVID-19 test. You say that per your doctor there is a global pandemic and 
you are allowed to get a COVID-19 test for any reason and the Plan cannot deny a COVID-19 test. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 
 
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 COVID-19 test provided on February 7, 2022, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies (K0553 and K0554). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies are necessary. 
The Plan denied your request. The Plan says the Medicare rules 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 use insulin with at least three daily administrations, 
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. Your records show you do not have either an insulin pump or 
multiple daily administrations of insulin. You are on oral medications and Ozempic, and do not take insulin at 
all. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the CGM and supplies (K0553 and 
K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair. 
 
You asked the Plan to pre-approve a heavy-duty manual wheelchair. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is specifically requested for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pre-approve a heavy-duty manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits provided on January 11, 2022, to May 
2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visits. You say that when you changed Plan's, you were told this 
provider was in-network. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advanced. 
 
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 psychotherapy visits provided on January 11, 
2022, to May 2, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2068), and take-home 
supply of buprenorphine (G2079) provided on May 3, 2021, to November 1, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the physician services. You say that your Medicare contract did not become 
effective until July 1, 2021. You also say that due to the coronavirus pandemic and staff shortages this was not 
submitted timely. The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider 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. Therefore, we 
decided that the Plan does not have to pay for the medication assisted treatment (G2068), and take-home 
supply of buprenorphine (G2079) provided on May 3, 2021, to November 1, 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 the remote physiologic monitoring treatment services 
provided on March 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the remote physiologic monitoring treatment services. You say that the 
procedure done was a part of your annual physical and you would like the claim paid. The Plan denied your 
request. The Plan says that the rendering provider is an OON provider and there was no approved 
authorization. 
 
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 the remote physiologic monitoring treatment 
services provided on March 31, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the surgical supplies provided to the
enrollee on November 30, 2021.
You asked the Plan to waive the coinsurance for the surgical supplies. You say that the enrollee never received
any durable medical equipment (DME) and should not be charged for it. The Plan denied your request. The
Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial. The Plan
requested a reopen. The Plan stated that this claim processed with a payment of $25,775.32 to the provider and
with a $1875.07 enrollee liability for the medical surgical supplies. The Evidence of Coverage explains there
will be a 20% coinsurance for Durable Medical Equipment (DME) and related supplies. The Explanation of
Benefits shows the enrollee liability of 20% is the coinsurance for the equipment used during the procedure.
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). The enrollee's contract with the
Plan clearly says that enrollees must pay a 20% coinsurance for medical supplies.
The enrollee has been asked to pay less than a 20% coinsurance for the surgical supplies. This item/service falls
within the medical supplies benefit category.
This means that the enrollee has been asked to pay less than 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 coinsurance for the surgical supplies provided
to the enrollee on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 2, 2022, to May 11, 
2022, while out-of-area. 
 
You asked the Plan to pay for chiropractic services while out-of-area. You say that while out-of-area you chose 
to see the provider who was able to relieve your pain. The Plan denied your request. The Plan says services 
were not medically necessary and do not meet Medicare criteria for coverage. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 pay for chiropractic services. Our physician 
reviewer found the record indicates that you have chronic back pain for over a year. The record provided does 
not indicate that you have had any acute injury or deterioration. The record provided does not establish the 
existence of an emergent or urgent condition, as defined by Medicare rules, requiring out of network care. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pay for chiropractic services provided on May 2, 2022, to May 11, 2022, while out-of-area.