Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that the enrollee is expected to get better 
with LTACH care. 
 
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. The patient 
appears to be more stable but is unlikely to benefit from long term acute care and should only require short-
term additional acute care services that can safely be administered at the current facility until appropriate for a 
lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH services. 
 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on August 2, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that you received bilateral custom foot orthotics and it 
was not for orthopedic shoes. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on August 2, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on July 9, 2021. 
 
You asked the Plan to pay for the services. You say that the provider was certified on this date of service. The 
Plan denied your request. The Plan says that this code is not eligible for payment. 
 
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. The plan has not provided a rationale as to why the rendering provider type is 
not appropriate for these services. The appellant stated that they were sending the registry form for review, but 
the plan has not provided this case document to MAXIMUS for review. Therefore, we decided that the Plan 
has to pay for anesthesia services provided to the enrollee on July 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment (97811). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of this service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the requested acupuncture treatment have not been met. Specifically, the record does not indicate that you have 
had chronic low back pain for twelve weeks or longer with no identifiable causes. Therefore, we decided that 
the Plan does not have to pre-approve acupuncture treatment (97811).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on February 23, 2022. 
 
You asked the Plan to pay for the office services. You say that you were not familiar with the PCP change 
requirements and would like to appeal the denied claim. The Plan denied your request. The Plan says this 
provider was not your assigned PCP. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You were not your assigned primary care physician. It was not until two months later on April 21, 2022, that 
you called into the health plan to change your primary care physician over to this provider. In order for the 
health plan to pay for services for your primary care visit, this provider would have needed to be assigned to your account prior to your visit. According to your page 44 of your 2022 EOC the change will occur on the 
first day of the month following the date of the request. Therefore, we decided that the Plan does not have to 
pay for the office services provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99497) provided on November 19, 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 99497 
is a column II code to column I code 90792 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 (99497) provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections (CPT code(s): 64493 and 64494) provided on 
January 18, 2022. 
 
You asked the Plan to pay for the injections. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT 64493-RT, 64493-LT, 64494-RT and 64494-LT has an MUE value of 1 but billed 2 units for both codes. 
Per the guidelines, we find the Medicare rule for payment of this date of service January 18, 2022, claim has 
not been met. If the provider determines that a billing error occurred during the initial submission of the denied 
claim, the plan will accept a submission of a corrected claim to consider services for payment. Based on this 
information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we 
decided that the Plan does not have to pay for the injections (CPT code(s): 64493 and 64494) provided on 
January 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on July 1, 
2021. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that by not being transported, you 
saved the Plan money. The Plan denied your request. The Plan says non-transport ambulance services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 1, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services you received on 
July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator. 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that spinal electrical osteogenesis stimulator (E0748) 
is covered only if any of the following criteria are met: 
Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
Following a multilevel spinal fusion surgery or 
Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same 
site. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has not had a multilevel 
spinal fusion surgery or spinal surgery with a prior failed spinal surgery at the same site. Based on this 
information, we decided that Medicare rules for coverage of a spinal electrical osteogenesis stimulator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a spinal electrical osteogenesis 
stimulator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to provide coverage for the computed tomographic (CT) angiography, heart, 
coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing 
(75574) provided January 25, 2022. 
 
You asked the Plan to provide coverage for the CT angiography including 3D image. You say that pre-
authorization was obtained prior to rendering services. Due to the medical needs of the enrollee, the procedure 
billed may differ slightly from the one that was pre-authorized. The Plan denied your request. The Plan says 
that this service is not covered because you did not contact the Plan for precertification. 
 
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. In this case there was no documentation provided indicating the need for prior 
authorization before performing the CT angiography. The EOC included in the file indicates that this 
information may be in the Schedule of Cost Sharing but this document was not included for review. 
Additionally, the provider claims that some form of prior authorization was obtained prior to the services being 
rendered but there is no response, explanation or documentation from the Plan explaining this.  Therefore, we 
decided that the Plan has to provide coverage for the computed tomographic (CT) angiography, heart, coronary 
arteries and bypass grafts (when present), with contrast material, including 3D image post processing (75574) 
provided January 25, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cosentyx (secukinumab) pen. 
 
You asked the Plan to pre-approve the Cosentyx pen. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says this is a self-injected medication that is not covered by 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 a Cosentyx (secukinumab) 
pen.  
 
Benefits for the Cosentyx pen 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667). 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the 
requested items have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen and has demonstrated failed response to at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression devices 
(E0652, E0667).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transport via wheelchair van you received on May 14, 2021. 
 
You asked the Plan to pay for the wheelchair van transport. You say that you would like the Plan to pay for this 
transport. The Plan denied your request. The Plan says transport by wheelchair van is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for transport via wheelchair van you received on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for LTACH 
admission, and that they cannot be adequately cared for in their current condition at a skilled nursing facility. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for LTACH and they can safely 
receive this care in a skilled nursing facility. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the outpatient treatment center at this time. The LTACH services are not medically necessary, 
reasonable, or appropriate for the diagnosis and condition of the enrollee and should be able to be furnished 
safely and effectively on an outpatient basis. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs these supplies. The 
Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Famotidine and the Odansetron you received while in an 
outpatient hospital setting on January 11, 2022. 
 
You asked the Plan to pay for the Famotidine and the Odansetron. You say that you would like these drugs paid 
for. The Plan denied your request. The Plan says self-administered drugs are not covered under your medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Famotidine and the 
Odansetron you received while in an outpatient hospital setting on January 11, 2022.   
Benefits for the Famotidine and the Odansetron 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the insulated gloves purchased on January 13, 
2022. 
 
You asked the Plan to reimburse you for the insulated gloves. You say that the gloves are for cold weather 
hiking and walking. You say that you inquired if the glove purchase was reimbursable. You also say that you 
were advised that reimbursement under the Wellness Wallet did apply. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the insulated gloves have not been met. Specifically, insulated gloves are not listed as covered 
under the Wellness Wallet benefit. Therefore, we decided that the Plan does not have to reimburse you for the 
insulated gloves purchased on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without 
contrast (70450) provided on January 30, 2022. 
 
You asked the Plan to pay for CT of the head or brain. You say that this service was billed appropriately and is 
supported in the record. The Plan denied your request. The Plan says a National Correct Coding Initiatives 
(NCCI) Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier 
indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was 
not billed with this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
 
 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 computed tomography (CT) of the head or brain without contrast 
(70450) provided on January 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81540) provided on 
January 27, 2021, by out-of-network providers. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the providers are out-of-network, the services were not referred by a network 
provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 81540) 
provided on January 27, 2021, by out-of-network providers.