Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on March 30, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is considered 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 the requested services. Our physician 
reviewer found that the CardioMEMS device consists of a sensor device placed in the pulmonary artery to 
allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure. 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in those in whom the CardioMEMS system was implanted, reflecting a patient population with 
preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS procedure.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Cardiac Rehabilitation Services on October 
29, 2021. 
 
You asked the Plan to waive the copayment for Cardiac Rehabilitation Services. You say that you were told the 
copayments would be covered completely. The Plan denied your request. The Plan says they are upholding the 
physician copayment for dates of services October 29, 2021. 
 
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 $25 
copayment for Cardiac Rehabilitation Services.  
 
You have been asked to pay a $25 copayment for Cardiac Rehabilitation Services. Cardiac Rehabilitation 
Services falls within the Cardiac Rehabilitation Services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for Cardiac Rehabilitation Services on October 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract removal procedure performed on 
December 6, 2021. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you had bruising that lasted 
for weeks. 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 a $345 
copayment for surgery or other services provided at an ambulatory surgical center.  
 
You have been asked to pay a $345 copayment for the cataract surgery. The cataract surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 a cataract removal 
procedure performed on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy, flexible, 
transoral; with biopsy, single or multiple provided on July 7, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy, flexible, transoral; with 
biopsy, single or multiple provided. You say that you were told prior to the procedure that you would receive 
no bill on the services in July 2021. You also say that when you inquired about the bill on your next visit with 
the provider, and was then told that it was not coded properly, and you should not have received a bill. The 
Plan denied your request. The Plan says you were 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 a $335 
copayment in an ambulatory surgical center for outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $335 copayment for an esophagogastroduodenoscopy, flexible, transoral; with 
biopsy, single or multiple provided. An esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or 
multiple provided falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple provided on July 7, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a hyaluronan injection provided on 
November 30, 2021. 
 
You asked the Plan to reduce the coinsurance for an injection. You say that you did not know it was going to 
cost that much for the gel shot the physician's assistant gave you. You also say that you received the shot and 
could not walk for ten days, then the provider gave you another shot to make it feel better. 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 claim was approved, and you have a cost sharing amount. You have been asked to pay 
$215.81, which is 20% of the allowed amount for an injection ($1,079.04 allowed amount x 20% coinsurance = 
$215.81). An 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 reduce the coinsurance for a hyaluronan injection provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided to the enrollee was 
medically necessary and would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 provided on October 20, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An Ultrasound provided on August 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An Ultrasound. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 An Ultrasound provided on August 12, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital surgery provided on December 22, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital surgery. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network office visit. 
 
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 outpatient hospital surgery provided on December 
22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on June 2, 2021, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869) insertion of interlaminar/interspinous process stabilization/distraction 
device (22870). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are appealing the denial for the 
placement of the Vertiflex device. The Plan denied your request. The Plan says this service is considered 
investigational as there is not sufficient evidence to establish safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met.  
 Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869) insertion of interlaminar/interspinous process stabilization/distraction 
device (22870).
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 these services. 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 17 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: 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. The Plan denied your request. The Plan says the enrollee is 
unlikely to benefit significantly from intensive therapy. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for cholecystitis and respiratory failure after Covid-19 
pneumonia and was discharged to skilled nursing. He does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The 
complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 20, 
2021. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service January 20, 
2021.
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 you do not have help at home. The Plan denied your 
request. The Plan says you do not require an intensive and coordinated interdisciplinary approach to 
rehabilitation. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for syncope and a vertebral compression fracture after a motor 
vehicle accident. Your medical problems are stable.  You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While you 
have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72193 billed for date of service November 
22, 2021. 
 You asked the Plan to pay for procedure code 72193. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72193 is bundled into payment for 
code 74160. 
 
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 72193 
is a column II code to column I code 74160. 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 72193 billed for date of service November 22, 
2021.