Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous laminotomy/laminectomy for decompression of neural elements (MILD procedure).
You asked the Plan to pre-approve MILD procedure. You say that this procedure is medically necessary for the enrollee and should be covered by the Plan. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the Plan is not responsible for coverage of services provided in a clinical trial.
The Plan follows Medicare rules. Medicare rules say that the MILD procedure is covered by Medicare through a Medicare-approved CED study, and that the Plan is responsible for payment of items and services in Medicare-approved CED studies unless Medicare determines otherwise. 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 MILD procedure. Our reviewer says that the enrollee meets the Medicare criteria for the requested MILD procedure. Our physician reviewer found the requested clinical study meets all Medicare criteria for coverage. This procedure is indicated for the enrollee and she has no contraindications. It is medically reasonable and necessary for the enrollee to receive this 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 MILD procedure have been met. Therefore, we decided that the Plan has to pre-approve percutaneous laminotomy/laminectomy for decompression of neural elements (MILD procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a consultation. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available.
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 consultation to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with removal of polyps 
(45385), subsequent tissue examination by a pathologist (88305), and destruction of internal hemorrhoids 
(46930) provided on March 5, 2021. 
 
You asked the Plan to waive the copayment for a colonoscopy, tissue examination, and hemorrhoid removal. 
You say that you have repeatedly had issues with billing from this provider and you feel the outpatient fee was 
not correctly applied in this situation. The Plan denied your request. The Plan says the cost-share was applied 
correctly according to your Plan benefits. 
 
 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 $245 
copayment for Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $245 copayment for a colonoscopy, tissue examination, and hemorrhoid 
removal. A colonoscopy, tissue examination, and hemorrhoid removal falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. Your procedures were conducted at an ambulatory surgery center. 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 with removal of polyps (45385), subsequent tissue examination by a 
pathologist (88305), and destruction of internal hemorrhoids (46930) provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that you are requesting an appeal for the denied 
authorization on the basis of medical necessity. The Plan denied your request. The Plan says the records do not 
support that the requested home ventilator is medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe chronic obstructive pulmonary disease, but there is no documentation 
of carbon dioxide retention with an arterial blood gas done while the enrollee is stable. Medicare does not cover 
a ventilator when used as bilevel positive airway pressure (BiPAP). Certain BiPAP devices can provide the 
average volume-assured pressure support mode of support. A home ventilator 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the scanning computerized ophthalmic 
diagnostic imaging you received on February 24, 2021, and the computed tomography (CT) scan of the chest 
and the positron emission tomography (PET) scan you had on March 12, 2021 
 
You asked the Plan to reduce the copayments for the scanning computerized ophthalmic diagnostic imaging, 
the CT scan, and the PET scan. You say that each of these services should have only been a $10 copayment. 
The Plan denied your request. The Plan says you were charged these copayments correctly.  The Plan says that 
for the scanning computerized ophthalmic diagnostic imaging, the allowed amount for this service ($81.12) is 
less than your copayment obligation, so 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 $210 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $210 copayment each for the scanning computerized ophthalmic diagnostic 
imaging, the CT scan, and the PET scan. The scanning computerized ophthalmic diagnostic imaging, the CT 
scan, and the PET scan all fall within the diagnostic radiology services benefit category. This means that you 
have been asked to pay the correct amounts 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 reduce the copayments for the scanning computerized ophthalmic diagnostic imaging you 
received on February 24, 2021, and the computed tomography (CT) scan of the chest and the positron emission 
tomography (PET) scan you had on March 12, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for positron emission tomography (PET) scan services provided 
on April 14, 2021. 
 
You asked the Plan to pay for the PET scan. You say that the radiology report provided supports the medical 
necessity of the services provided and the validity of the codes billed. The Plan denied your request. The Plan 
says diagnosis code C61 is specifically called out as not a medically necessary diagnosis for code 78815. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that diagnosis code C61 does not support medical necessity 
when billed with an FDG PET and is nationally non-covered.  
 
We looked at the file and Medicare rules. The records show that the PET scan in dispute was billed with 
diagnosis code C61. Based on this information, we decided that Medicare rules for coverage of the PET scan 
have not been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography 
(PET) scan services provided on April 14, 2021.
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 SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says the rules for SNF care have not been met. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you have remained medically stable. You 
do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can 
receive further rehab services at a lower level of care. Although further rehab 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 his baseline and he can receive services at a lower level of care.  
Admission to a SNF for inpatient skilled rehab 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 care 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: Favorable

We decided that the Plan does not have to pay for radiation therapy services provided to the enrollee on
October 29, 2019 and billed under code 77344.
You asked the Plan to pay for radiation therapy coded as 77344. You say that this claim should be paid. The
Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan says that the claim in
question was not submitted with the correct 'type of bill' code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due
to an error with the "type of bill" code. Medicare billing criteria for the services billed are not met. Therefore,
we decided that the Plan does not have to pay for radiation therapy services provided to the enrollee on October
29, 2019 and billed under code 77344.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical treatment of a metacarpal fracture 
provided by an in-network hospital on November 23, 2020. 
 
You asked the Plan to waive the copayment for hand surgery. You say that you went in for day surgery at a 
hospital, but you were never admitted and feel you should not be charged. The Plan denied your request. The 
Plan says the claim was processed correctly for surgery performed by an in-network outpatient hospital. 
 
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 Outpatient Hospital Services.  
 
 
 You have been asked to pay a $325 copayment for hand surgery. Hand surgery falls within the Outpatient 
Hospital Services benefit category. The in-network benefit for Surgery Services conducted in an outpatient 
hospital setting clearly states a $325 copayment applies. 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 surgical treatment of a metacarpal fracture provided by an in-network hospital on November 23, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee on April
26, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the services coded are provided vaginally, however the enrollee is a male. The QIC
overturned the Plans denial stating the records show the enrollee is female. The Plan requested a reopen and
provided records to show the enrollee was born as and is listed as a male.
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. In this case, the services
reported cannot be paid as they are described as vaginal services and the enrollee is a male. Medicare rules for
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for
emergency room services provided to the enrollee on April 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no trial and failure of other treatment methods.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found in this case, there is no documentation that the enrollee has had a trial and failure of at least 2 out of 3 of the following treatment methods: at least one course of physical therapy (PT) for knee osteoarthritis; at least 2 pharmacologic therapies (oral or topical NSAIDs, acetaminophen, tramadol or duloxetine) with documentation provided; and/or at least 2 injections of intra-articular corticosteroids (such as Orthovisc and Monovisc) to the affected knee. Therefore, the review has determined that the service at issue 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous transcatheter placement of stent (92929) 
provided on May 25, 2021. 
 
You asked the Plan to pay for stent placement. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because code 92929 is 
always bundled for payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 92929 is always bundled for payment, and 
if it is covered the payment for it is subsumed by the payment for the service to which it is incident.  
 
We looked at the file and Medicare rules. Code 92929 is always bundled for payment and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of stent placement have not 
been met. Therefore, we decided that the Plan does not have to pay for percutaneous transcatheter placement of 
stent (92929) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a SPECT scan, a nuclear medicine service, 
provided by a participating provider on July 22, 2021. 
 
You asked the Plan to reduce the copayment for a diagnostic nuclear medicine service. You say that you 
believe the coding was incorrect for the procedure as it occurred in an office setting specifically designed for 
the type of procedure you received rather than a hospital. You say the copayment should be lower. The Plan 
denied your request. The Plan says your claim was processed correctly. The Plan contacted the provider?s 
office and confirmed the service at issue was rendered in an outpatient hospital setting. 
 
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 $495 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  You have been asked to pay a $495 copayment for a diagnostic nuclear medicine service. Nuclear medicine 
services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
The providing facility is affiliated with a hospital health system. Consequently, billing is conducted by the 
hospital health system itself. 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 reduce the copayment for a SPECT scan, a nuclear 
medicine service, provided by a participating provider on July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on June 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 the services (70450) provided on June 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 1, 2020 to December 30, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like these claims reprocessed and 
approved for payment. The Plan denied your request. The Plan says required information is missing on the 
claim for the billed dates of service. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. In this case, the original 
claim cannot be paid as billed due to the omission of the appropriate codes that allow payment. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from December 
1, 2020 to December 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from June 8, 2021, to July 16, 2021. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you disagree 
with the charges and the outpatient hospital facility charges. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 $0 
copayment for outpatient rehabilitation services provided at a specialist's office or comprehensive outpatient 
rehabilitation facility and a $40 copayment when provided at an outpatient hospital facility. You received outpatient rehabilitation services at an outpatient hospital facility from June 8, 2021, to July 16, 
2021, for a total of 10 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total 
amount you owe is: $40 (copayment) x 10 (visits) = $400.  
 
You have been asked to pay the total copayment amount of $400 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments for outpatient rehabilitation services provided from June 8, 2021, to 
July 16, 2021.