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

 
We decided that the Plan does not have to waive the copayments for the ambulance transportation and the 
emergency room visit provided on November 10, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation and the emergency room visit. 
You say that you should not be held responsible since you did not want to be brought to the emergency room. 
The Plan denied your request. The Plan says the proper copayments were applied for the services that were 
rendered. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for each Medicare-covered one-way trip by ground ambulance and a $90 copayment each 
emergency care visit within the United States.  
 
You have been asked to pay a $295 copayment for the ambulance transportation and a $90 copayment for the 
emergency room visit. The ambulance transportation falls within the Ambulance services benefit category. The 
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 copayments for the ambulance transportation and the emergency room visit provided on November 10, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750) provided November 9, 
2021. 
 You asked the Plan to pay for the anti-reflective coating. You say that your husband's claim from this provider 
was covered. The Plan denied your request. The Plan says your eyewear claim has been reprocessed; however 
the anti-reflective coating is not a covered service. 
 
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 contract states that the Plan does not cover anti-reflective coating. 
 
Though the Plan offers routine vision benefits in excess of Medicare coverage, the anti-reflective coating is not 
among those covered services. Therefore, we decided that the Plan does not have to pay for the anti-reflective 
coating (V2750) provided November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606). 
 
You asked the Plan to pre-approve the automatic external defibrillator. You say that clinical documentation and 
medical studies are included within the attachments to substantiate the medical necessity of the LifeVest. The 
Plan denied your request. The Plan says the records do not support that the enrollee meets the Medicare 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the automatic external defibrillator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic atrial fibrillation and had a near syncopal episode 
in church; subsequent hospital records suggested dehydration as the basis of the episode, with no evidence of 
ventricular arrhythmias on ECG monitoring. The WD is a vest like device worn under the clothing that 
continuously monitors the heart rhythm and automatically delivers an electric shock when VF or VT is 
detected. This device is intended to be worn continuously, 24 hours per day, except when the wearer is bathing 
or showering. As such, it would not appear that the enrollee is a candidate for a WD according to current 
guidelines. In summary, authorization and coverage of the WD would not be considered medically necessary in 
this enrollees clinical management. 
 
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 automatic external defibrillator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
16, 2021. 
 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 December 16, 
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for code 77014.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information
regarding the denial. The Plan says that the appeal is not tied to medical necessity but to appropriate billing
practices. The Plan states that code 77301 was billed on May 27, 2021. The was reimbursed to the non -
participating provider. The Medicare billing guidelines state that CT guidance for radiation therapy fields will
not be separately billed during the duration of the IMRT treatment when code 77301 is billed. Payment for the
services identified by code 77014 is included in the APC payment for code 77301 (IMRT planning). These
codes should not be reported in addition to code 77301 when provided prior to or as part of the development of
the IMRT plan.
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, code 77014
cannot be paid as billed as it is not a separately payable code in this instance. Therefore, we decided that the
Plan does not have to pay for computed tomography (CT) scan services provided to the enrollee from June 14,
2021, to June 18, 2021, and billed under code 77014.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) supplies 
(A7033, A7035, A7037, A7038) purchased on November 3, 2021. 
 
You asked the Plan to pay for CPAP supplies. You say that this has been covered in the past. The Plan denied 
your request. The Plan says these items were purchased from a provider that does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for continuous positive airway pressure 
(CPAP) supplies (A7033, A7035, A7037, A7038) purchased on November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multi-level radiofrequency ablation (procedure 64636) 
provided to the enrollee on July 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 64636-RT (3 Units) remains not supported, as the 
medical records submitted don't support an injection of three additional levels. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64636 is "Destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report documents 
"radiofrquency in the lumbar region medial branch neurotomy at the right L3 level, right L4 level, right L5 level, and right S1 level." In this case, the documentation supports a total of three levels. The additional unit is 
not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for multi-level radiofrequency ablation (procedure 64636) provided to the enrollee on July 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve a repeat lumbar ESI. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a repeat lumbar ESI have not been met. Specifically, medical records were not provided. Without 
this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does 
not have to pre-approve a repeat lumbar epidural steroid injection (ESI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care after April 16, 
2022. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like reconsideration because the SNF 
care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage for the SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you did not require any skilled services 
on an inpatient basis, at a SNF level of care as of April 16, 2022. 
You did not have any parenteral medications, complex wound care or nutrition given via a feeding tube.  Your 
functional improvement had plateaued by the date in question and you did not require any further inpatient 
skilled rehab services. Your function was at or near your prior level of function and you could be discharged to 
a lower level of care for further services.  As of April 16, 2022, you required custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skilled Nursing Facility (SNF) care after April 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four levels left lumbar Radiofrequency Ablation. 
 
You asked the Plan to pre-approve four levels left lumbar Radiofrequency Ablation. The Plan denied your 
request. The Plan says the Medicare LCD guidelines has limits of no more than 1 to 2 levels, either unilateral 
or bilateral, per spine region is injected per session. The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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 two levels left lumbar Radiofrequency 
Ablation. Our reviewer says that two subsequent levels left lumbar Radiofrequency Ablation does not meet the 
Medicare coverage criteria. Our physician reviewer found according to the coverage criteria, the guidelines 
have limits of no more than 1 to 2 levels, either unilateral or bilateral, per spine region per session. Therefore, 
partial approval was given for 2 levels. In this case, the provider has requested radiofrequency ablation at 4 
levels. The review has determined that the requested subsequent left lumbar radiofrequency ablations does not 
meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two subsequent levels left lumbar Radiofrequency Ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve two subsequent levels left lumbar 
Radiofrequency Ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prescription custom fabricated foot insert, each, removable 
(L3010) purchased September 22, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that the custom foot orthotics are a medically necessary 
form of treatment of his foot symptoms. 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 prescription custom fabricated foot 
insert, each, removable (L3010) purchased September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from
June 24, 2021 to July 23, 2021.
You asked the Plan to pay for these services. You say that continued skilled nursing facility services medically
necessary. The Plan denied your request. The Plan says at the point of notice the enrollee did not require daily
skilled nursing services such as the administration of IV antibiotics, the management and education of a new
PEG tube or ostomy, or the complex management of wounds.
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. The medical records show that as of
the date of notice, the enrollees care had become custodial in nature and daily skilled therapy and/or daily
skilled nursing services at a facility level of care were no longer needed. 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 pay for skilled nursing facility services provided to the enrollee from June 24, 2021 to
July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block x 1 for right knee (CPT 64624). 
 
You asked the Plan to pre-approve genicular nerve block x 1 for right knee. The Plan denied your request. The 
Plan says a genicular nerve block x 1 for right knee is experimental and investigational because the 
effectiveness for this indication has not been established by peer reviewed medical studies. 
 
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 genicular nerve block x 1 for right 
knee. Our reviewer says that the requested genicular nerve block x 1 for right knee is not considered medically 
reasonable and necessary. Our physician reviewer found genicular nerve blocks and genicular nerve 
radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic 
knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the 
knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for 
individuals who are not candidates for knee replacement surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block x 1 for right knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve block x 1 for right knee (CPT 64624).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71111. 
 
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 71045 
is a column II code to column I code 71111. 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 71045 billed for date of service November 11, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive the cost share charged for a hospital bed provided on June 8, 2021.
You asked the Plan for these services. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included
documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually
eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid
may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal
care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information.
Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid,
but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage.
The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not
have to pay for these services under the Medicare benefit. Therefore, we decided that the Plan does not have to
waive the cost share charged for a hospital bed provided on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 25, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 36011: 
 
Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) 
 
CPT 75820: 
 
Venography, extremity, unilateral, radiological supervision and interpretation  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 36011, the 
operative report does not describe (per NCCI Policy Manual) "Through puncture in skin, physician passes a 
needle into the vein and threads a guidewire through the needle into the vein and the wire is removed. A first 
order branch from the vena cava.". To cite the procedure report "Left common posterior tibial vein."  his 
procedure cannot be verified. In terms of CPT 75820, this procedure would not be covered, as it would be 
performed with CPT 36011, which cannot be verified as performed, and is not supported by the procedure 
report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on October 25, 2021.