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

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the enrollee is unable to take non-steroidal anti-
inflammatory drugs due to chronic kidney disease. The Plan denied your request. The Plan says the enrollee 
has not tried and failed Orthovisc and Supartz FX. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyalgan. Our physician reviewer found 
that the enrollee has a Baker's cyst of the knee. The Plan requires a trial of Orthovisc or Supartz FX before they 
will approve the requested drug. The case file does not contain documentation of trial and failure of Orthovisc 
or Supartz FX. The documentation does not support that Orthovisc or Supartz FX would likely be less effective 
or would likely have adverse effects for the enrollee in this case. Furthermore, the documentation does not 
support that the enrollee has osteoarthritis of the knee, for which Hyalgan would be indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not need medical monitoring by a rehabilitation doctor. 
 
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. You 
are medically stable and does not need physical medicine and rehabilitation physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no rehab nursing needs identified or documented in the record. While you may benefit 
from physical and occupation therapy, your rehab can be safely provided at a lower intensity and alternate 
setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) provided on December 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that your dentist had to check your teeth from a fall. 
You say that your tooth chipped off more.  You say that you were given an appointment for December 30, 
2021. You also say that the service was necessary. The Plan denied your request. The Plan says the oral exam 
denied correctly. 
 
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 and oral exams are listed as covered, 
the frequency limit of 2 visits per year has been exceeded. The record shows that the Plan paid for oral exams 
that you received on June 3, 2021, and July 14, 2021. Therefore, we decided that the Plan does not have to pay 
for the oral exam (D0120) provided on December 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not 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 item. Our reviewer says that  Our 
physician reviewer found  
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 20, 2021 to 
March 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must report one of the three 
Q codes (Q5001, Q5002, and Q5009). 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with one of the 
required Q codes. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered on February 20, 2021 to March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 11, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan presented documentation to show that
this claim denied because the provider billed this service inappropriately. The Plan submitted specific
documentation of only 18 drug classes counted from the laboratory results received. The Plan states there is
another more appropriate code for the services provided and the provider billed the wrong code.
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 Plan has
provided lab results to show less than 22 classes were tested, meaning this claim was not coded appropriately.
Medicare uses another code for testing resulting in less than 22 classes of drugs. Therefore, we decided that the
Plan does not have to pay for drug testing provided to the enrollee on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rheumatology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Rheumatology services. You say that you would like service from an OON 
provider. The Plan denied your request. The Plan says the medical care the enrollee requires can be provided 
by a network rheumatologist. 
 
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 
Rheumatology services 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 Nitro Duet Rollator Transport chair (E1399). 
 
You asked the Plan to pre-approve Nitro Duet Rollator Transport chair. You say that your doctors were not 
given enough time to respond, and judgement was rushed without all of the facts. The Plan denied your request. 
The Plan says this is an upgraded device that exceeds the medical needs of the enrollee. 
 
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 Nitro Duet Rollator Transport chair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not support that the enrollee has a mobility 
limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily 
living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the 
home. The documentation does not support that the enrollees mobility limitation cannot be sufficiently 
resolved by the use of an appropriately fitted standard walker or that the enrollees home provides adequate 
access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is requested. 
There is no evidence that the enrollee is unable to engage in activities in the home that cannot be performed in 
a standard wheelchair. The documentation does not support that the patient requires a Nitro Duet Rollator over 
a standard wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nitro Duet Rollator Transport chair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Nitro Duet Rollator Transport chair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service s (99053) provided on September 11, 2021. 
 
You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 
99053 has a status indicator of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services provided between 10:00 PM and 8:00 AM have not been met. Therefore, we decided that the 
Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition 
to basic service s (99053) provided on September 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215), the prolonged office or other 
outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure 
(G2212), and the nasal spray (S0013) rendered by the out-of-network (OON) provider on November 5, 2021. 
 
You asked the Plan to pay for this item/services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the item/services were rendered by an out of 
network provider, without prior authorization. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan 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 had network providers available 
who could have provided the item/services at issue in this appeal. The Plan did not pre-approve the 
item/services at issue. We found no exception that would require the Plan to pay for this item/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99215), the prolonged office or 
other outpatient evaluation and management service(s) beyond the maximum required time of the primary 
procedure (G2212), and the nasal spray (S0013) rendered by the out-of-network (OON) provider on  
November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lyme disease laboratory test (86618) 
provided on August 12, 2021. 
 
You asked the Plan to waive the copayment for the lyme disease laboratory test. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 $10 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $10 copayment for a lyme disease laboratory test. Lyme disease laboratory tests 
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 laboratory test (86618) provided on August 12, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that your doctor told you that a 
procedure would take 3 days to be approved so you went to the emergency room instead. The Plan denied your 
request. The Plan says the copayment amount you are being charged is correct. 
 
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 $100 
copayment for emergency care.  
 
You have been asked to pay $100 copayment for emergency room visit. Emergency room visit falls within the 
Emergency 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 an emergency room visit provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam you had on June 17, 2021. 
 
You asked the Plan to waive the copayment. You say that you were told that you didn't owe anything. The Plan 
denied your request. The Plan says you are responsible for the copayment. 
 
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 $30 
copayment for each medical eye exam.  
 
Review of the file shows that you had a medical eye exam on June 17, 2021. You have been asked to pay a $30 
copayment for the exam. The exam 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 eye exam you had on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on November 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 75726 (radiological supervision and interpretation of 
abdominal angiography) and 37242 (vascular embolization or occlusion). Code 75726 is a column II code with 
a modifier indicator of 1 when billed with column I code 37242. Code 75726 was not billed with an appropriate 
modifier to allow for separate payment. The -59 modifier is not supported as a separate and distinct procedural 
service. Therefore, we decided that the Plan does not have to pay for the imaging services rendered on 
November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve MyoPro orthotic device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental. 
 
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 MyoPro orthotic device. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards 
and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term 
use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment 
(98941) rendered by the out-of-network (OON) provider on October 28, 2021 and November 19, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan 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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment (98941) 
rendered by the out-of-network (OON) provider on October 28, 2021 and November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the ultrasound (76805) rendered 
by the out-of-network (OON) provider on September 24, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan 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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the office visit (99203) and the ultrasound (76805) 
rendered by the out-of-network (OON) provider on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested porcelain crown, core buildup, and upper 
and lower partial dentures to be provided from an out-of-network (OON) dentist. 
 
You asked the Plan to pre-approve the requested OON dental services. You say that you need these services 
and were not aware that the authorization was denied. The Plan denied your request. The Plan says your benefit 
does not cover OON dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, this coverage is limited to services 
provided by a network dentist. Therefore, we decided that the Plan does not have to pre-approve the requested 
porcelain crown, core buildup, and upper and lower partial dentures to be provided from an out-of-network 
(OON) dentist.