Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medial unloader knee brace. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee brace is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the you have chronic knee changes and 
pain. There is no documentation of recent trauma, surgery, or knee instability. The criteria for coverage are not 
met and the knee brace is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a medial unloader knee brace.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred by your regular dentist. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for out-of-network (OON) 
specialist services provided on August 7, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for the OON specialist services. You say that you 
did not know the provider was out-of-network. The Plan denied your request. The Plan says the correct 
deductible and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 out-of-network deductible which applies to certain items and 
services.  
 
Your contract with the Plan also clearly says that you must pay a 30% coinsurance for each visit with an out-
of-network specialist. 
 
 
 The OON specialist services fall within the Physician/Practitioner Services, Including Doctor's Office Visits 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
out-of-network deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the OON specialist services were received on August 7, 2021.  
 
The file shows that on the date of service, you had a total of $363.98 remaining to meet your deductible. This 
amount is applied first, leaving a remaining allowed amount of $0.67. Of this amount, you are then responsible 
for the 30% coinsurance of $0.26, however, you were only charged $0.13. The total for all services is $364.11. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This 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 deductible and coinsurance for out-of-network (OON) specialist services provided 
on August 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency medical transportation (NEMT). 
 
You asked the Plan to pre-approve NEMT. You say that you require non-emergent medical transportation to 
and from your doctor appointment. The Plan denied your request. The Plan says the documentation does not 
indicate that you require personal assistance. 
 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 routine transportation when medically necessary.  
 
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, the file does not 
indicate that you require personal assistance walking or getting into or out of the vehicle. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency medical transportation (NEMT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service  
April 30, 2022. 
 
You asked the Plan to pay for procedure code 70544. The Plan denied your request. The Plan says payment for 
code 70544 is bundled into payment for code 70511. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (62320) provided to the enrollee on July 19, 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 records provided are missing data elements that are required by Medicare. Maximus overturned the Plans denial stating the services were medically appropriate. The Plan requested a reopen and stated that Maximus did not recognize the required data that was missing. The Plan indicated that code 62320 is a non-covered code for Medicare claims and the procedure notes are incomplete as they are not dated.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. The rules also say that the medical records provided must support the services billed. The medical records provided are not properly signed and dated for the date of service listed on the claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (62320) provided to the enrollee on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided to the enrollee on November 1, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. The rules also say that the medical records provided must support the services billed. The medical records provided are not properly signed and dated for the date of service listed on the claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for pain management services provided to the enrollee on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the physician service. You say that you feel you need a higher level of care. 
You say that you were not satisfied with the outcome of your surgery and course of recovery. You say that you 
do not feel comfortable having a reversal done by anyone associated with your previous surgeon or their group. 
The Plan denied your request. The Plan says there are in-network providers available within the contracted 
Medical Group. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 
network providers associated with the contracted Medical group available who can provide the items/services 
at issue in this appeal. The file indicates that if after an evaluation with an in-network provider, the provider 
feels that the out-of-network provider is necessary, then the out-of-network provider can be approved at that 
time. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided 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 the enrollee meets LTACH criteria. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 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: Favorable

 
We decided that the Plan has to pay for an automatic external defibrillator (AED) garment (K0606) billed for 
date of service October 10, 2021. 
 
You asked the Plan to pay for an AED garment. You say that you have provided documentation to support the 
item billed. The Plan denied your request. The Plan says that rules for payment have not been met because the 
item at issue was not billed correctly. 
 
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. Specifically, the Plan has denied payment for the item at issue because the 
modifiers billed are inappropriate. However, the Plan has not provided an explanation of why each modifier is 
not appropriate to the enrollee's situation. 
 
The item at issue was billed with modifiers RR, KI and KX. Modifier RR indicates the item is rented, which is 
supported in the case record. Modifier KI indicates the second or third month of rental, which is supported in 
the case record. Modifier KX indicates that the item at issue continues to be medically necessary and is 
appropriate in this case. 
 
It is the Plan's responsibility to substantiate its denial. In this case, the denial has not been adequately 
supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for an automatic 
external defibrillator (AED) garment (K0606) billed for date of service October 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an arthrodesis device (22612). 
 
You asked the Plan to pre-approve implantation of an arthrodesis device. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have 
not been met because the requested service is experimental/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 implantation of an arthrodesis device. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested service would be an off-label use of the device, which is meant 
to be used with bone grafts and not as a standalone procedure. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of an arthrodesis device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of an arthrodesis device (22612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone HCL. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone HCL.  
 
 
 Benefits for the requested drug 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 20, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 20, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on March 29, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-ray. 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 x-ray provided on March 29, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine ophthalmological examination including refraction 
provided on April 18, 2022. 
 
You asked the Plan to pay for a routine ophthalmological examination including refraction. You say that last 
time it was covered, and nobody told you it had changed. The Plan denied your request. The Plan says services 
were rendered with an out-of-network provider and are not covered.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of a routine ophthalmological examination including refraction have not been met. Specifically, 
services were rendered with an out-of-network provider and are not covered. Therefore, we decided that the 
Plan does not have to pay for a routine ophthalmological examination including refraction provided on April 
18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue are billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met because you billed multiple 
individual codes with the same date of service. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 14, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232 and 81355.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hormone replacement therapy (HRT) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve HRT. You say that you have never been hospitalized. You say that your 
plan has never had to pay for services for you. You also say that when you began seeing this provider, they 
were the only hormonal physician in your area. The Plan denied your request. The Plan says the requested 
services can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there is a 
network provider available who can provide the HRT at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-
approve hormone replacement therapy (HRT) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator rental to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a home ventilator rental to be provided by an OON provider. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested item can be 
provided by a 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve a home ventilator rental to be provided by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS-3D testing (88104, 88305, 88312, 88361) provided 
on September 16, 2021. 
 
You asked the Plan to pay for WATS-3D testing. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
services at issue require modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made under the physician fee 
schedule for the professional component of physician laboratory or physician pathology services furnished to 
hospital inpatients or outpatients. 
 We looked at the file and Medicare rules. In this case, the professional and technical components were 
furnished in different settings. The claims at issue were not billed with modifier -26 to indicate the professional 
component. Based on this information, we decided that Medicare rules for coverage of WATS-3D testing have 
not been met. Therefore, we decided that the Plan does not have to pay for WATS-3D testing (88104, 88305, 
88312, 88361) provided on September 16, 2021.