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

 
We decided that the Plan does not have to pay for ambulance services provided on July 8, 2022. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment 
   
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 ambulance services provided on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic footwear (L3215). 
 
You asked the Plan to pre-approve Orthopedic footwear. You say that you have a loss of sensation of the right 
leg from the knee down. 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 pre-approve orthopedic footwear (L3215).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve ten surgical extractions. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the procedure submitted may be more accurately represented by 
another code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says the code requested is not the appropriate service to provide. 
Medical records were not submitted to support the requested service is not appropriate. The Evidence of 
Coverage clearly states that extractions are a covered benefit up to your benefit maximum of $2500. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the denial of the requested 
service has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to 
pre-approve ten surgical extractions. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on June 25, 2022. 
 
You asked the Plan to pay for anesthesia. You say that the enrollee was not enrolled in hospice. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
   
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 anesthesia provided on June 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated abutment  includes placement tooth #29 
(D6057), and abutment supported porcelain/ceramic crown tooth #'s 20 and 29 (D6058). 
 
You asked the Plan to pre-approve the custom fabricated abutment  includes placement tooth #29 (D6057), 
and abutment supported porcelain/ceramic crown tooth #'s 20 and 29 (D6058). You say that you submitted an 
appeal letter that indicates you had approval for the service in 2022.  You also ask to please approve the 
services. The Plan denied your request. The Plan says that the maximum cap has been reached on your 
coverage. 
 
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. Specifically, the Plan did not substantiate their denial reason because there is no 
evidence of the maximum cap coverage having been met. Therefore, we decided that the Plan has to pre-
approve a custom fabricated abutment  includes placement tooth #29 (D6057), and abutment supported 
porcelain/ceramic crown tooth #'s 20 and 29 (D6058).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day management provided on April 5, 2022. 
 
You asked the Plan to pay for discharge day management. You say that the services were provided on April 5, 
2022, and the enrollee was not admitted to hospice until April 6, 2022. The Plan denied your request. The Plan 
says original Medicare is responsible for payment. 
   
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 discharge day management provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740 x 2) and core buildups (D2950 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee is in pain, has palatial erosion 
and has an immediate need for these services. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on authorization number 0043125608 and 
appeal A23088160532 when the Plan approved three crowns and three core buildups. Therefore, we decided 
that the Plan does not have to pre-approve crowns (D2740 x 2) and core buildups (D2950 x 3).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve all lower extremity prostheses, flex-walk system or equal (L5981) 
and all lower extremity prostheses, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says that the items are not medically necessary. 
 
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 items. Our physician reviewer 
found the documentation provided supports the use of the requested transtibial prosthesis with K3 components. 
The enrollee is currently walking using an iwalker and the enrollee's K inventory score is that of a K4 
ambulator. The enrollee's residual limb incision site has healed, and the enrollee has been using a stump 
shrinker. Therefore, the requested flex-walk system (L5981) and multi-axial rotation unit (L5986) are 
medically necessary. 
 
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 items have been met. Therefore, we decided that the Plan has to pre-approve 
all lower extremity prostheses, flex-walk system or equal (L5981) and all lower extremity prostheses, multi-
axial rotation unit (L5986).  
 
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: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for dialysis treatment. We decided that the Plan does not have to waive the coinsurance for dialysis treatment.

You asked the Plan to waive the coinsurance for out-of-network dialysis treatment provided on April 1, 2022, and April 30, 2022.. You say that you went to a different nephrologist and the provider said you did not need dialysis. The Plan says that this cost sharing was charged correctly.

We decided that the Plan has to reduce the coinsurance for dialysis treatment.

The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a 20% coinsurance for services to treat kidney disease.

The Plan says you must pay $61.98 for dialysis treatment. Based on the Plan contract, however, you cannot be asked to pay more than 20%, $61.49 ($307.43 x 20% coinsurance = $61.49 coinsurance) for dialysis treatment. Therefore, we decided that the Plan has to reduce the coinsurance for dialysis treatment.

We also decided that the Plan does not have to waive the coinsurance for dialysis treatment.

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 20% coinsurance for dialysis treatment. Therefore, we decided that the Plan does not have to waive the coinsurance for dialysis treatment.

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 the crowns (D2740) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have corrected the coding as it was an 
oversight and would like the corrected claim processed. The Plan denied your request. The Plan says the 
procedure code submitted appears to be wrong for the procedure being performed. 
 
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 incorrect code was submitted on 
the original claim. Therefore, we decided that the Plan does not have to pay for the crowns (D2740) provided 
on June 14, 2022.  
 
We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We 
cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan 
for further review. We are only permitted to make a decision based on the claim information reviewed by the 
Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4215 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code A4215. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4215 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4215 is statutorily excluded from Medicare payment. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4215 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4215 billed for date of service September 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on October 10, 
2022, through October 13, 2022. 
 
You asked the Plan to pay for the outpatient hospital services as billed. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says OCE unit 51 must be corrected for 
this claim to be processed. 
 
The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital claims must be processed 
through the IOCE. OCE edit 51 is invoked when HCPCS code G0378 is reported more than once on a 013x or 
085x claim/bill type. 

We looked at the file and Medicare rules. Procedure code G0378 is reported more than once. The edit is 
applicable to the subsequent lines of G0378 only. Therefore, we decided that the Plan does not have to pay for 
the outpatient hospital services provided on October 10, 2022, through October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual swingaway (E1028), a foot lock (E2206), and 
an angled footplate (K0040). 
 
You asked the Plan to pre-approve the manual swingaway, foot lock, and footplate.. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says these items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a swingaway, retractable, or removable hardware 
(E1028) is non-covered if the primary indication for its use is to allow the beneficiary to move close to desks or 
other surfaces.  
 
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 manual swingaway, foot lock, and 
footplate. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the 
enrollee is not a high risk for skin breakdown. The enrollee has mobility in the chair and does not perform a 
slide transfer. 
 
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 manual swingaway, foot lock, and footplate. have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a manual swingaway (E1028), a foot lock (E2206), and 
an angled footplate (K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, paravertebral facet 
joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636 
x 6). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary. The Plan states although the enrollee 
has had these procedures performed previously, records provided do not clearly explain why treatment at five 
levels bilaterally is necessary, or why a more targeted approach will not be beneficial. 
 
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 services. Our physician reviewer 
found the Plan has approved two levels of injection bilaterally. The additional three levels are not medically 
reasonable and necessary at this time, based on the LCD. There is insufficient documentation of medical 
necessity of therapeutic facet joint injection at three additional levels. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636 x 6).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral mastopexy and axillary liposuction provided on 
March 11, 2022. 
 
You asked the Plan to pay for the bilateral mastopexy and axillary liposuction. You say that you feel that this 
should be covered as it was medically needed. The Plan denied your request. The Plan says the implant 
removal and capsulotomy were approved to pay; however, the breast lift and liposuction are mainly cosmetic 
and noncovered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 bilateral mastopexy and axillary 
liposuction. Our reviewer says that the services provided in this case are not considered medically necessary reconstructive surgery and are mainly cosmetic in nature. Our reviewer found the enrollee had undergone 
several cosmetic breast procedures in the past with saline implants subglandular. In 2017, the enrollee had 
bilateral breast implants exchange to submuscular silicone gel textured and periareolar mastopexies. The 
enrollee complained of severe itching on the right breast, but there was no rash. The enrollee self-paid for the 
removal and reconstruction. The available documentation does not support that the surgical services at issue in 
this case are considered reconstructive. Mastopexy is cosmetic breast surgery to lift the breasts. The 
documentation does not support that axilla anterior liposuction was reconstructive. The documentation does not 
support that the services were medically reasonable and necessary for this 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 bilateral mastopexy and axillary liposuction have not been met. Therefore, 
we decided that the Plan does not have to pay for the bilateral mastopexy and axillary liposuction provided on 
March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that failure to get treatment will impact your health. 
The Plan denied your request. The Plan says services are available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
additional pain management services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care following an elective left 
total shoulder arthroplasty (23472). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The 
Plan denied your request. The Plan says you are undergoing a planned elective left total shoulder arthroplasty. 
The Plan states you are medically stable and have been provided medical clearance to undergo this elective 
procedure. The Plan states the planned procedure listed under CPT code 23472 is not listed on the Centers for 
Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is currently approved 
as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the 
enrollee will require a greater than two midnight stay. The Plan states if you experience any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with 
updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found there is no documentation of uncontrolled co-morbidities which in-and-of-themselves 
are expected to require a prolonged hospital stay.  You should present for and undergo the procedure as an 
outpatient. Should complications arise, necessitating a prolonged stay, you can be converted to inpatient status 
at that time under the two-midnight rule. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care following an elective left total shoulder 
arthroplasty (23472).