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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on November 10, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was transported from the 
hospital to nursing home following a fall. You also say that the ambulance services were medically necessary. 
The Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance services. Our reviewer says 
that the non-emergent ambulance services were not medically necessary. Our physician reviewer found the 
provided documentation does not support that other means of transport (such as stretcher van, wheelchair van) 
were contraindicated for the enrollee. The reviewer found that the documentation does not support that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport. The reviewer also found that the documentation does not support that 
the ambulance transport on November 10, 2021, was medically reasonable and necessary for the enrollee. 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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on 
October 13, 2021. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you were told you would 
not be responsible for the injection. You also say this service should be covered. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for in-network part B drugs.  

The record shows this is covered by the Plan, but also that you have a cost sharing responsibility. You have 
been asked to pay $254.28, which is 20% of the allowed amount for a denosumab injection ($1,271.40 allowed 
amount x 20% coinsurance = $254.28). A denosumab injection falls within the Medicare Part B Prescription 
Drugs 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 coinsurance for a denosumab injection provided 
on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (99100) provided on June 29, 2021. 
 
You asked the Plan to pay for code 99100. You say that you would like the Plan to reconsider their denial of 
payment. 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. 
 
We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99100) provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor for the enrollee.
You asked the Plan to provide coverage for a continuous glucose monitor. You say that a continuous glucose
monitor for the enrollee is medically necessary. The Plan denied your request. The Plan says the Medicare
coverage criteria are not met. Maximus overturned the Plans denial for a lack of medical records in the file. The
Plan requested a reopen and provided the required medical records.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at
least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose
testing results and have had an in-person visit with their treating physician to assess adherence to their CGM
regimen and diabetes treatment plan.
Based on the medical records provided, the enrollee does not meet all of the required criteria. While it is
understood the device would be beneficial for the enrollee to use, all of the required criteria listed in the
Medicare rules must be met for coverage to be approved. Therefore, we decided that the Plan does not have to
provide coverage for a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-evaluation (D0170), provided on January 5, 2021.
You asked the Plan to pay for the re-evaluation. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-evaluation (D0170), provided on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia (J0717) to be injected once monthly. 
 
You asked the Plan to pre-approve Cimzia. You say that the enrollee advised they are unable to give themself 
injections. You say that the enrollee would have to come to the office weekly as a result. You also say that this is not feasible for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed 
the preferred drugs, Enbrel, Humira, Rinvoq, Skyrizi, and Xeljanz/Xeljanz XR. 
 
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 Cimzia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed one of the preferred drugs. the reviewer also found that the documentation 
does not support that Enbrel, Humira, Rinvoq, Skyrizi, and Xeljanz/Xeljanz XR would likely be less effective, 
and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the 
step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cimzia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimzia (J0717) to be injected once monthly.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that this is medically necessary. The Plan denied 
your request. The Plan says that you do not have any stated contraindications to the preferred products. 
 
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 Simponi Aria. Our reviewer says that 
Simponi Aria is not medically reasonable and necessary. The Plan requires a trial of Humira, Enbrel, Xeljanz 
or Rinvoq before they will approve the requested drug. In this case, you have not tried and failed the required 
drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not 
meet step therapy criteria for Simponi Aria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88305, 88312) provided on 
November 8, 2021. 
 
You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim is included in payment to the 
facility. 
 
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 looked at the file and Medicare rules. Specifically, the records indicate that the member was an outpatient 
on the billed date of service. Payment for the billed pathology services  is included in the payment to the 
facility and is the responsibility of the facility to any vendor. Based on this information, we decided that 
Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan 
does not have to pay for the pathology services (88305, 88312) provided on November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prostatic artery embolization (PAE) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of PAE in the setting of lower urinary tract 
symptoms (LUTS) secondary to BPH have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. PAE is considered an 
experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have 
demonstrated possible short-term safety and efficacy. The most recent American Urological Association 
(AUA) guidelines do not recommend this procedure outside of a clinical trial setting. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prostatic artery embolization (PAE) for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lipid testing provided on September 14, 2021. 
 
You asked the Plan to pay for the lipid testing. You say that you would like this covered and approved for 
payment. The Plan denied your request. The Plan says while this might have been medically appropriate, this 
service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that routine screening and prophylactic testing for 
lipid disorder are not covered by Medicare. While lipid screening may be medically appropriate, Medicare by 
statute does not pay for it. Based on this information, we decided that Medicare rules for coverage of the lipid 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the lipid testing 
provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 5, 2021, to 
January 9, 2021, at the billed Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 871 is not supported as the primary diagnosis of sepsis, unspecified organism (A41.9) is 
not supported in the medical record. The Plan argues that DRG 689 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. DRG 871 requires a primary diagnosis of sepsis, organism 
unspecified (A41.9). 
 
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 pay for inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. 
Our physician reviewer found that the documentation from the medical record provided for review supported 
an admission for further evaluation and treatment of an enrollee with a history of dementia. She presented to 
the emergency department (ED) with her daughter and reports from nursing home that she was lethargic and 
not responding to verbal stimuli. It is noted in the record that the enrollee complained about her left wrist 
hurting. After further review, the enrollee was noted to have a positive UTI. The enrollee remained 
hemodynamically stable in the ED. Although sepsis was documented in the physicians' notes, there was 
insufficient evidence of life-threatening organ dysfunction caused by a dysregulated host response to infection. 
There must be a rise of 2 or more points in the SOFA score that cannot be easily explained by causes other than 
sepsis. The review has determined that the medical records did not support the billing of sepsis, unspecified 
organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 5, 2021, to January 9, 2021, 
at the billed Diagnosis Related Group (DRG) 871.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision of a reconstructed breast (19380) provided on 
December 11, 2020. 
 
You asked the Plan to pay for the revision of a reconstructed breast. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service 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 code 19380 is revision of reconstructed breast (eg, significant 
removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular 
revision combined with soft tissue excision in implant-based reconstruction). 
 
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 revision of a reconstructed breast.  Our reviewer says that CPT code 19380 does not meet criteria for billing or reimbursement consideration. Our 
reviewer found operative report does not include sufficient documentation to support shaping the breast(s) and 
making them as symmetric as possible. In this case operative report describes reduction of an aerola. 
 
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 revision of a reconstructed breast have not been met. Therefore, we decided 
that the Plan does not have to pay for the revision of a reconstructed breast (19380) provided on December 11, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0143), provided on September 25, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a walker. You say that the item was medically necessary. The Plan denied your 
request. The Plan says the equipment was ordered 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 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 a walker (E0143), provided on September 25, 
2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology (88305) services provided on June 28, 
2021. 
 
You asked the Plan to pay for code 88305. You say that you would like the Plan to reconsider their denial of 
payment. 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. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the records indicate that the 
member was an outpatient on the billed date of service. Payment for CPT code 88305 is included in the 
payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the 
Plan does not have to pay for the surgical pathology (88305) services provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a hearing aid (V5261), provided on August 6, 2021. 
 
You asked the Plan to pay for a hearing aid. You say that the services should be covered. The Plan denied your 
request. The Plan says that services were obtained through an out-of-network provider without prior-
authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids with up to a $500 allowance. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid have been met. Specifically, the Plan's EOC does not say that you must use certain 
providers for their supplemental hearing benefit. Therefore, we decided that the Plan has to pay for a hearing 
aid (V5261), provided on August 6, 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.