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

 
We decided that the Plan does not have to pre-approve Tramadol. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tramadol.  
 
 
 Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 21, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with this edit. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 36556. 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 imaging services provided to the enrollee on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services 
provided on August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on January 3, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that it is the facilities responsibility to 
obtain the authorization and you would like the claim to be paid. The Plan denied your request. The Plan says 
the rendering provider is an OON 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 ophthalmological services provided on January 
3, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of the Vertiflex Superion Device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in 
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, 
from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis (including the planned level of implantation, L4-5.) FDA contraindications include 
spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical 
records. There is imaging evidence of grade 1 anterolisthesis of L4, grade 1 retrolisthesis of L1, with no 
discussion of spinal instability on flexion/extension films. There is no documentation of the enrollees height, 
weight or body mass index. There is no discussion of scoliosis of the lumbar spine, with no documentation of a 
Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant 
osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex 
Superion interspinous device at L4-5 is not medically reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of the Vertiflex Superion Device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic manipulation provided on November 22, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a chiropractic manipulation. You say that your office, individual provider, as 
well as the referring provider are participating providers with Medicare. The Plan denied your request. The 
Plan says the rendering provider is a non-participating provider, and there is no referring provider involved in 
these services. The Plan also says they did not authorize any services for this provider and facility. 
 
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 chiropractic manipulation provided on 
November 22, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve assessment of home, physical and family environment, 
to determine suitability to meet patient's medical needs as maintained by CM for a second wheelchair. 
 
You asked the Plan to pre-approve assessment of home, physical and family environment, to determine 
suitability to meet patient's medical needs as maintained by CM for a second wheelchair. The Plan denied your 
request. The Plan says the enrollee already had four in-home assessments, the last of which was  
December 19, 2021, which shows no indication that enrollee's condition has changed, and enrollee already has 
a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that 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 assessment of home, physical and 
family environment, to determine suitability to meet patient's medical needs as maintained by CM for a second 
wheelchair. Our reviewer says that assessment of home, physical and family environment, to determine 
suitability to meet patient's medical needs as maintained by CM does not meet the Medicare coverage criteria. 
Our physician reviewer found that the reviewed documentation indicates that you have a power wheelchair that 
is one to two years old that is in very good condition. You use it as your primary means of mobility. The 
request for an additional manual wheelchair is not medically necessary, as other options can be arranged so that 
your safety when attending swimming activities could provide the safety and comfort that you require. You 
have a powered wheelchair that is one to two years of age, is in very good condition and that you use as your 
primary means of mobility. The provision of an additional manual wheelchair so that you can attend swimming 
activities is not deemed medically necessary, and as stated, other options can be arranged so that your safety 
when attending swimming activities could provide the safety and comfort that you require.  The review has determined that the requested assessment of home, physical and family environment, to 
determine suitability to meet patient's medical needs as maintained by CM does not meet the Medicare 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of assessment of home, physical and family environment, to determine suitability 
to meet patient's medical needs as maintained by CM for a second wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve assessment of home, physical and family environment, to 
determine suitability to meet patient's medical needs as maintained by CM for a second wheelchair.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for an injection, technetium, and thallium. We also 
decided that the Plan does not have to waive the cost share for a nuclear medicine study.  
 You asked the Plan to waive the cost share for an injection, technetium, thallium, and a nuclear medicine study. 
You say that you do not think you owe this bill. The Plan says that you have been charged the correct cost 
sharing amount. 
 
We decided that the Plan has to waive the cost share for an injection, technetium, and thallium provided 
on August 9, 2021. 
 
The Plan says you must pay 20% coinsurance for an injection (code J2785), technetium (code A9500), and 
thallium (code A9505). According to Medicare, codes J2785, A9500, and A9505 are packaged codes and are 
not separately payable. Therefore, we decided that the Plan has to waive the cost share for an injection, 
technetium, and thallium provided on August 9, 2021. 
 
We also decided that the Plan does not have to waive the cost share for a nuclear medicine study 
provided on August 9, 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 $110 
copayment for radiological diagnostic services, including nuclear studies. 
 
You have been asked to pay a $110 copayment for a nuclear medicine study (code 78452). A nuclear medicine 
study falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 cost share for a nuclear medicine study provided on August 9, 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80047, 83880, 85014) and the 
hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on November 16, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without a prior authorization or referral. 
 
 
 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 in cases involving emergencies, out of 
area urgent care and pre-approved care. Additionally, the Point of Service (POS) benefit allows enrollees with 
a referral from a primary care physician to access services from non-network providers.  
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
The Plan did not receive a referral from the enrollees primary care physician. We found no exception that 
would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (80047, 83880, 85014) and the hospital outpatient clinic visit (G0463) rendered by the 
out-of-network (OON) provider on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient radiation oncology treatment. 
 
You asked the Plan to pre-approve . The Plan denied your request. The Plan says  
 
Your complaint is not a valid appeal for medical coverage. The record does not show that the Plan denied 
coverage of the outpatient radiation oncology treatment provided by Cape Cod Hospital. Instead, you have 
asked the Plan to waive any cost-sharing that may be applied for these services when they are provided. 
Maximus Federal Services cannot review requests related to cost-sharing for services that have not yet taken 
place. Your complaint is a grievance that must be answered by the Plan directly. Therefore, we decided that the 
Plan does not have to pre-approve the outpatient radiation oncology treatment.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve twelve (12) additional PT visits. 
 
You asked the Plan to pre-approve twelve (12) additional PT visits. You say that additional PT is medically 
necessary. The Plan denied your request. The Plan says that additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 twelve (12) additional PT visits. Our 
reviewer says that additional PT is medically necessary. Our physician reviewer found physical therapy is a 
generally accepted as specific and effective therapy for your condition. Although, you have met some of your 
documented therapy goals and have had some overall improvement, you are still requiring more advanced 
assistive device than stated goal and require physical assistance with mobility tasks. In addition, it is 
documented that you are receiving treatment from a care provider for foot drop and muscle spasms 
(botox injections and bracing) thus continued therapy will require specialized skill of a professional therapist to 
safely and effectively assess and provide treatment. The amount of physical therapy sessions requested are 
appropriate and you are not yet functionally stable to solely rely on a stable home exercise plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of twelve (12) additional PT visits have been met. Therefore, we decided that the 
Plan has to pre-approve twelve (12) additional PT visits.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 15, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on January 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 21, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with this edit. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on January 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract removal surgery provided on March 23, 2021, by an 
out-of-network (OON) provider. 
 You asked the Plan to pay for cataract removal surgery. You say that your practice attempted to obtain prior 
authorization, however, you were unable to obtain authorization for these claims as there was no response at 
the Plan's office. You also say that as medical providers we felt it was prudent and necessary to continue to 
treat our patients and made the determination to continue all necessary medical protocols, despite your failure 
to return your phone calls. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan, and the services were not referred by a network provider or rendered in an in-network facility. 
The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 cataract removal surgery provided on March 23, 
2021, by an out-of-network (OON) provider.