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

 
We decided that the Plan does not have to waive the copayment for ER visit provided on August 05, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that this should be covered. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
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 $65 
copayment for Emergency care. 
 
You have been asked to pay a $65 copayment for ER visit. This item/service falls within the Emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ER visit provided on August 05, 
2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve dental implants. The Plan denied your request. The Plan says the request is 
not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment provided on September 26, 2022. 
 
You asked the Plan to pay for medication assisted treatment. You say that you are Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The Plan denied your request. The Plan says that 
Medicare guidance instructs only to reimburse claims for SAMHSA certified providers at a facility level, but 
individual physicians are not SAMHSA certified. 
 
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. This provider is SAMHSA certified in accordance with Medicare rules. The Plan 
has not provided any other evidence or rationale to support a denial of payment for this service. Therefore, the 
Plan has not shown that its decision to deny payment for this service is correct or justified according to 
Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment provided on 
September 26, 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 Trivisc. 
 You asked the Plan to pre-approve Trivisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Trivisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not support 
that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on October 05, 2021. 
 
You asked the Plan to pay for the drug testing. You say that medical records were submitted to support medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on October 05, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 28, 
2020. 
 
You asked the Plan to pay for the coronavirus test. You say that the claim should be reprocessed for payment 
based on the current federal guidelines for coronavirus testing and reimbursement. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 28, 
2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says that the code has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 has an MUE 
value of 2. Code 76641 was billed on 2 separate claim lines with modifiers LT and RT as required. Based on 
this information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, 
we decided that the Plan has to pay for procedure code 76641 billed for date of service September 1, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), a comprehensive oral evaluation 
(D0150), and bitewings (D0274), provided by an out-of-network provider on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told until after your appointment 
that they did not accept your insurance. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for prophylaxis (D1110), a comprehensive oral evaluation (D0150), and bitewings (D0274), provided by 
an out-of-network provider on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral exam (D0120), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional image (D0230) and panoramic radiographic 
image (D0330) provided on August 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you asked the provider if they accepted 
your insurance, they said yes. Therefore, you do not feel you should have to pay for the services. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Panoramic radiographic image 
(D0330) - one procedure every three plan years. You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. You 
previously received panoramic radiographic image (D0330) on July 15, 2021. Therefore, this benefit was 
exhausted on July 15, 2021. Therefore, we decided that the Plan does not have to pay more for periodic oral 
exam (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
image (D0230) and panoramic radiographic image (D0330) provided on August 5, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 12011 billed for services provided on June 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are separate procedures. The Plan 
denied your request. The Plan says that the procedure is included within the global surgery package of code 
23500. 
 
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 12011 is simple repair of superficial wounds of face, 
ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less. We find that CPT code 12011 is a clearly 
distinct surgical procedure from the clavicle repair (code 23500) provided on June 20, 2022. Code 12011 was 
unrelated to the diagnosis for which the surgical procedure code 23500 was performed. Code 12011 was not 
due to complications from code 23500. Based on this information, we decided that Medicare rules for coverage 
have been met. Therefore, we decided that the Plan has to pay for procedure code 12011 billed for services 
provided on June 22, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on August 13, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the code 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 99285 is an Emergency Department visit with medical 
decision making of a high complexity. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this code is not supported in 
the record as the records describe the patient as stable with an uncomplicated presentation. Based on this 
information, we decided that Medicare rules for coverage of the emergency room services have not been met. 
Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided on 
August 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and consultation (99205, 99215, 88321) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and consultation. You say that the requested office visits are 
medically necessary. The Plan denied your request. The Plan says the enrollee must use network providers to 
get her medical care and services. These services can be provided by in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and consultation (99205, 99215, 88321) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004), scanning computerized 
ophthalmic diagnostic imaging (92134) and a determination of refractive state (92015) provided on April 20, 
2022. 
 
You asked the Plan to pay for a medical eye examination (92004), scanning computerized ophthalmic 
diagnostic imaging (92134) and a determination of refractive state (92015). You say that the provider did not 
tell you that you needed a referral from your primary doctor. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a medical eye 
examination (92004), scanning computerized ophthalmic diagnostic imaging (92134) and a determination of 
refractive state (92015) provided on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 25, 2021 
to November 28, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services were medically necessary. The Plan denied your request. The Plan says 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a secondary diagnosis of J96.01, acute respiratory 
failure with hypoxia. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the secondary diagnosis code billed is not 
supported in the records. Our physician reviewer found there was no clinical or laboratory evidence of acute 
respiratory failure with hypoxia in the records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 25, 2021 to November 28, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport. 
 
You asked the Plan to pay for the ambulance transport. The Plan denied your request. The Plan says our policy 
covers non-emergency ambulance transportation when it is the only way to transport a member safely and 
adequately, or if other means of transporting a member are unsafe due to a medical condition. 
 
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 transport. Our reviewer says 
that the service was not medically necessary. Our physician reviewer found the enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means without endangering the enrollee's 
condition. 
  
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 transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transport.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator implant (64555, 64590). 
 
You asked the Plan to pre-approve the nerve stimulator implant. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless other 
treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did 
not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient. 
 
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 nerve stimulator implant. Our reviewer says that the nerve stimulator is not medically necessary. Our physician reviewer found provided 
records do not show that all other modalities had been exhausted. Surgery was recommended, but it was 
unclear if this was pursued. 
 
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 nerve stimulator implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a nerve stimulator implant (64555, 64590).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs more time in the SNF to evaluate 
her issues before she is cleared to go home. You say that the enrollee is an extremely high fall risk and is 
disoriented. The Plan denied your request. The Plan says the enrollee no longer requires skilled services on a 
daily inpatient basis in a SNF. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.