Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option and a custom frame color for a 
wheelchair. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says although these items are requested, no allowed amount is listed on the quote 
submitted. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transit option and a custom frame color for a wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful for the treatment of this 
health problem. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the non-radiating midline back pain, the noted pain-aggravating and pain-relieving factors, 
along with the diminished and painful spinal motion (in all directions) were/are all non-specific to any 
pathologic entities. In this case, there were/are multiple plausible pathologic sources of significant pain 
generation. Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the request for Intracept intraosseous basivertebral nerve ablation at L4 and L5 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), sphere, bifocal, plano to plus or minus 
4.00d (V2200) and anti-reflective coating (V2750) provided February 10, 2022, by an out-of-network (OON) 
provider. 
 You asked the Plan to pay for the frames and lenses with anti-reflective coating. You say that the Plan is 
making an error. The Plan denied your request. The Plan says vision services are not covered when provided 
OON. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided in-network. 
 
We looked at the file and the Plan's rules. In this case the routine eyewear was provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the frames and lenses with anti-reflective coating 
have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020), sphere, 
bifocal, plano to plus or minus 4.00d (V2200) and anti-reflective coating (V2750) provided February 10, 2022, 
by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced life support (ALS) (A0433), and ground 
mileage (A0425) provided on November 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim denied correctly. 
 
 
 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 advanced life support (ALS) (A0433), and ground 
mileage (A0425) provided on November 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the open treatment of distal radial intra-
articular fracture provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for the open treatment of distal radial intra-articular fracture. You 
say that you only receive $1,000 dollars a month from your social security check and this copayment would 
take a lot out of her check for the month. 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 $350 
copayment per day for other outpatient procedures and services, including, but not limited to outpatient surgery 
performed in an outpatient hospital or ambulatory surgical center.  
 
 
 
 You have been asked to pay a $350 copayment for the open treatment of distal radial intra-articular fracture. 
The open treatment of distal radial intra-articular fracture 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 the open treatment of distal radial intra-articular fracture provided on 
January 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture coded 87150 and the infectious agent detection by 
nucleic acid coded 87641 provided on September 19, 2021. 
 You asked the Plan to pay for the culture and the infectious agent detection by nucleic acid. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not 
payable as 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, we have confirmed that code 87150 
is a column II code to column I code 87500. We have confirmed that code 87641 is a column II code to column 
I code 87150. 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 the culture coded 87150 and the infectious agent detection by nucleic acid coded 87641 provided on 
September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on September 16, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. 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 authorization is 
required prior to an out-of-network 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 chiropractic care provided on September 16, 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 Monoferric. 
 
You asked the Plan to pre-approve Monoferric. You say that you would like the plan to reconsider their 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 Monoferric. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Infed (iron dextran) and Venofer (iron sucrose). The documentation does not support any indication 
that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for the outpatient surgery services provided on 
October 5, 2021. 
 
You asked the Plan to lower the copayment for the outpatient surgery services. You say that you have gone to 
the clinic before, and the copayment was lower. The Plan denied your request. The Plan says the proper 
copayment was applied for what the provider billed. 
 
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 $150 
copayment for Medicare-covered outpatient hospital surgery services. The total allowed amount was $134 
which is less than the copayment amount of $150. Therefore, only $134 was charged as the copayment. 
 
  You have been asked to pay a $134 copayment for the outpatient surgery services. The outpatient surgery 
services 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 lower the copayment for the 
outpatient surgery services provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the transportation is 
medically necessary. The Plan denied your request. The Plan says mileage beyond the 75 miles, one way, is not 
covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when trips limited to 75 miles, one-way.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional non-emergency transportation mileage.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve additional routine trips. You say that you are missing your appointments. 
You say that you do not have transportation to get to them. The Plan denied your request. The Plan says 
additional trips beyond the allowed 24 per year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 2 additional non-emergent transportation trips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home healthcare. 
 
You asked the Plan to pre-approve home healthcare. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 home healthcare. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found you not have documented skilled 
nursing needs or skilled therapy needs. As such, home healthcare services, as well as associated HHA services, 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home healthcare have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home healthcare.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the pacemaker replacement procedure (33228) by an out-of-
network provider. 
 
You asked the Plan to pre-approve the pacemaker replacement procedure. You say that the enrollee is an 
established patient, and it is important for continuity of care that this service is provided by you. The Plan 
denied your request. The Plan says that this service has been requested by an out-of-network provider. 
 
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 did not forward to us medical records to support their denial of this 
claim. Without medical records it is not possible for us to determine if there was a continuity of care concern 
with this claim. Therefore, we decided that the Plan has to pre-approve the pacemaker replacement procedure 
(33228) by an out-of-network provider.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from October 25, 2021, 
to October 31, 2021. 
 
You asked the Plan to pay for SNF care. You say that these services were medically necessary, and this claim 
was billed accurately to the services provided. The Plan denied your request. The Plan says that the HIPPS 
code billed for this claim does not match what was pre-approved by the Plan. 
 
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. We find that the Plan did not submit a compelling denial rationale in this case. 
The claim was denied due to lack of authorization for the SNF services. However, the Plan has attested that the 
SNF services were authorized with a HIPPS code that was calculated at the time that the approval was 
requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that 
the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the 
enrollees actual condition and the services actually rendered during the statement period of the claim. It would 
therefore be expected that the billed code would differ from a code that was estimated prior to the services 
being rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are 
incorrect or not supported, only that the code, as a whole, was not approved. We find that this denial of 
payment has not been substantiated. Therefore, we decided that the Plan has to pay for skilled nursing facility 
(SNF) services provided from October 25, 2021, to October 31, 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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your medical and therapy needs could be met in a skilled nursing unit. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for non-operative management of shoulder fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on January 7, 2022. 
 
You asked the Plan to pay for the next generation sequence (NGS) testing panel. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
not covered. 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the NGS testing panel performed 
included testing for the FANCC gene. This means the entire panel is not covered. Based on this information, 
we decided that Medicare rules for coverage of the next generation sequence (NGS) testing panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the next generation sequence (NGS) testing 
panel provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that the laboratory services billed are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file shows that more than one code was submitted for this panel provided. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 22, 
2022.