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

 
We decided that the Plan does not have to pay for an x-ray examination of the neck and spine, an x-ray 
examination of the jaw, an x-ray examination of teeth, an x-ray examination of the chest, a radiologic 
examination of the spine, cervical, an influenza immunization, a pneumococcal vaccine, and an office visit 
provided on November 4, 2021, by an out-of-network (OON) provider. 
 You asked the Plan to pay for an x-ray examination of the neck and spine, an x-ray examination of the jaw, an 
x-ray examination of teeth, an x-ray examination of the chest, a radiologic examination of the spine, cervical, 
an influenza immunization, a pneumococcal vaccine, and an office visit. You say that there are no contracted 
providers that could have provided this services in the way this provider can, to eliminate transporting. The 
Plan denied your request. The Plan says based on the information provided, the requested service are available 
within the Plan network of providers, and this provider is not a network contracted provider. The Plan also says 
that the prior authorization was denied at the time of service. 
 
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 an x-ray examination of the neck and spine, an x-
ray examination of the jaw, an x-ray examination of teeth, an x-ray examination of the chest, a radiologic 
examination of the spine, cervical, an influenza immunization, a pneumococcal vaccine, and an office visit 
provided on November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusions, for therapy, prophylaxis, or diagnosis, 
and a ceftriaxone sodium injection, and a daptomycin injection provided on November 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for intravenous infusions, for therapy, prophylaxis, or diagnosis, and a ceftriaxone 
sodium injection, and a daptomycin injection. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the services are not authorized because this provider is a non-network 
provider who does not work with the Plan, and the member was referred by a provider who also does not work 
with the Plan. The Plan also says that the member's primary care physician did not refer for services, and they require utilization of network providers when possible and available, and requires authorization for certain 
services. The Plan also says that no medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. 
 
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 intravenous infusions, for therapy, prophylaxis, or 
diagnosis, and a ceftriaxone sodium injection, and a daptomycin injection provided on 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 a telehealth visit provided on January 27, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the telehealth visit. You say that you would like the claim reprocessed for 
payment. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 telehealth visit provided on January 27, 2022, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services, medical 
examination and evaluation provided on January 3, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmological services, medical examination and 
evaluation. You say that this visit should be included as a follow-up to your surgery and be covered. The Plan 
denied your request. The Plan says the visit on January 3, 2022 was 91 days after the surgery and is not within 
the global fee period of 90 days.  
 
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 $45 
copayment for Vision Care.  
 
You have been asked to pay a $45 copayment for the ophthalmological services, medical examination and evaluation. The ophthalmological services, medical examination and evaluation falls within the Vision Care 
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 ophthalmological services, 
medical examination and evaluation provided on January 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the record sent by your provider indicates no record of recent physical therapy, 
chiropractic therapy, acupuncture, aggressive medical management therapy with both narcotic and non-narcotic 
pain medication. 
 
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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has not exhausted evidence-based conservative therapy for his pain. He does not 
meet the criteria for the placement of a SCS. The request is not medically reasonable or necessary at this point. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 3, 2021. 
 
You asked the Plan to waive the copayment for ECG. You say that you want to know why there is 
coinsurance/copayment for this type of procedure, and you do not believe that you should be responsible to pay 
this amount. The Plan denied your request. The Plan says you were 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare-covered non-radiological diagnostic services. for Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 You have been asked to pay $13.57, which is less than the $20 copayment for an ECG. ECG falls 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 an electrocardiogram (ECG) provided on December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 3, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that according to your benefits you 
don't have a copayment for diagnostic testing. The Plan denied your request. The Plan says the copayment was 
applied 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 $25 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay $25 for an ultrasound. An ultrasound falls 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 
the ultrasound provided on February 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you feel that SNF care is necessary. The 
Plan denied your request. The Plan says you do not require daily skilled services. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is not shown to have an acute decline in function. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, be provided at a lower 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Diagnostic Radiology provided on October 25, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Diagnostic Radiology services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the prior authorization was denied at the time 
of service; therefore, the claim was also denied. 
 
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 Diagnostic Radiology provided on October 25, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the refraction provided on October 18, 
2021. 
 
You asked the Plan to waive the copayment for physician services. You say that are appealing the cost share 
applied. The Plan denied your request. The Plan says you have been charged the correct copayment 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 an in-
network $10 copayment for exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay an in-network $10 copayment for the refraction. The refraction falls within the 
Vision care 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 the refraction provided on 
October 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for debridement services provided to the enrollee on December 9, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that there was no need to add procedure code 11045 to the claim. 
 
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 11045 is "Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each 
additional 20 sq cm, or part thereof (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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the procedure report documents "25 sq cm 
debrided, and skin substitute, first 25sq cm. In this case, provider would report CPT 11042 for the first 20 sq 
cm debridement, and CPT 11045 for the additional 5 sq cm debridement. Then for skin substitute CPT 15271 
would be billed for the first 25 sq cm, to cover the 25 sq cm debridement.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
debridement services provided to the enrollee on December 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 20, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you spoke with customer service 
and there was no record of the claim. The Plan denied your request. The Plan says you have been charged the 
correct copayment 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 $155 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or free standing facility.  
 
 
 
 
 You have been asked to pay a $155 copayment for an ultrasound. An ultrasound falls 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 an ultrasound provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 21, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you have been going to the same provider 
and did not know an authorization was need. You would like for the claim to be covered. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. It was also confirmed that the enrollee never contacted the Plan to verify 
the providers network status. Also, the service rendered was not urgent or emergent. 
 
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 specialist office visit provided on January 21, 
2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on April 20, 2018. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you have had colonoscopies 
before, and that they were taken care of. The Plan denied your request. The Plan says the medical records were 
reviewed, and it confirmed that the colonoscopy was not a preventative colonoscopy. Therefore, the proper 
copayment was applied for the service that was rendered. 
 
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 $325 
copayment for surgical services in an Outpatient Hospital Facility.  
 
  You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 colonoscopy provided on April 
20, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve uvulopalatopharyngoplasty (UPP) for the enrollee.
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan
denied your request. The Plan says Medical necessity has not been established. 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 reopen request. At issue is coverage for uvulopalatopharyngoplasty (UPP).
The Maximus Physician Reviewer determined that the requested procedure is considered medically reasonable
and necessary in this case. The reviewer found that the enrollee is troubled with loud snoring and daytime
sleepiness. The most recent sleep study in 2013 showed mild obstructive sleep apnea with AHI of 8.4. There
was no REM sleep, so this may be an underestimate of the severity of the apnea. The enrollee has tried
continuous positive airway pressure in the past but was intolerant.
The Plan requested a reopen and stated that the possibility of a higher AHI using a sleep study that is 9 years
old with no reported RDI is insufficient to disregard Medicare guidance. The Plan states that even if one would
say that the RDI was equated to the AHI, the number of events is far lower than the appropriate criteria needed
to approve the requested surgery.
Our Medical Director has concluded that the Plan is correct in this case. The enrollee is a 66-year-old woman
with diagnosis of obstructive sleep apnea. Overnight polysomnography on February 21, 2009, showed
improvement in the enrollee's upper respiratory resistance syndrome and oxygen saturation. The Apnea Index
and the Hypopnea Index were both 0.0. A Nocturnal Polysomnogram on May 16, 2013, revealed very mild
sleep-disordered breathing worse while supine. The Apnea Hypopnea Index (AHI) was 8.4 per hour of sleep.
The supine AHI was noted to be 10.1. On November 21, 2019, it is documented that the enrollee was not using
her CPAP machine and oral splint as she needs. A letter dated November 18, 2021, states that the enrollee has
been undergoing treatment for sleep apnea after not being able to tolerate CPAP titration therapy. The enrollee
"had the nasal procedure" and was then "undergoing oral and hypopharynx treatment." "She is status post
tonsillectomy and needs UPPP and Tongue Base procedure." Based on the medical records provided, the
documentation is insufficient to demonstrate that a uvulopalatopharyngoplasty was medically reasonable and
necessary for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve uvulopalatopharyngoplasty (UPP) for the enrollee.