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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
September 22, 2021, to September 28, 2021. 
You asked the Plan to pay for the SNF care provided from September 22, 2021, to September 28, 2021. You 
say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the 
SNF benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 28, 2021, 
to September 21, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from September 22, 
2021, to September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayments for the office visits (99204, 
99214) and the external mobile cardiovascular telemetry and electrocardiographic recording; with review and 
interpretation (93228) provided from August 18, 2021, through October 19, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for in-network specialist office visits.  
 
 You have been asked to pay $70.52 ($25 + $25 + $20.52). This amount includes a $25 copayment for the 
specialist office visits provided on August 18, 2021 and October 19, 2021. Additionally, this amount includes a 
$20.52 copayment for the external cardiovascular telemetry provided by an in-network specialist on  
September 21, 2021, which is less than the applicable copayment for this service. 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 issue reimbursement of the copayments for the office visits (99204, 99214) and the external mobile 
cardiovascular telemetry and electrocardiographic recording; with review and interpretation (93228) provided 
from August 18, 2021, through October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an ophthalmologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an OON office visit with an ophthalmologist. You say that this is the nearest 
provider in your area. The Plan denied your request. The Plan says there are in-network ophthalmologist 
specialists available to provide the service 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 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 with an ophthalmologist to be provided by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
29, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service December 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (49568) provided October 20, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the code billed cannot be paid. 
 
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 49568 
is an add-on code and has not been billed with an appropriate primary procedure code.  Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (49568) provided October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 25, 2020, to May 11, 2020. 
 
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 DRG was updated in this case.  
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 DRG 177 (RESPIRATORY INFECTIONS AND 
INFLAMMATIONS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was admitted and treated in the hospital for pneumonia and acute on 
chronic respiratory failure. At home, he required 5L oxygen support and in the hospital it was increased to 7L. 
He was not noted to be in acute distress or had any work of breathing. There were no arterial blood gas results 
showeing significant oxygen reduction. The diagnosis of acute respiratory failure was not sufficiently 
supported in the documentation.  
 
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 to the enrollee from April 25, 2020, to May 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the Plan approved transportation to an 
appointment that was over 50 miles in 2020. You also say there is no other provider available with the Plan that 
can provide the service you need. The Plan denied your request. The Plan says you are requesting an additional 
75 miles for a total of 125 miles and your benefit only allows 50 miles. 
 
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 up to 24 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  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. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glucose monitoring (82962) provided July 21, 2021. 
 
You asked the Plan to pay for the glucose monitoring. You say that the service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a 
diabetes diagnosis. Based on this information, we decided that Medicare rules for coverage of the glucose 
monitoring have not been met. Therefore, we decided that the Plan does not have to pay for glucose monitoring 
(82962) provided July 21, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vyvgart (efgartigimod alfa-fcab) treatments. 
 
You asked the Plan to pre-approve the Vyvgart treatments. You say that the enrollee meets the criteria for use 
of this drug. The Plan denied your request. The Plan says that the documentation does not support that the use 
of this drug is indicated for this enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Vyvgart treatments. Our reviewer 
says that the requested drug treatment is considered medically reasonable and necessary. Our physician 
reviewer found the member is noted to have acetylcholine receptor (AChR)-positive myasthenia gravis, a 
condition for which Vyvgart is indicated for use. It would otherwise be generally considered to be an 
appropriate treatment option for the member at this time. The requested drug would be considered to be safe for 
the member. While the exact efficacy cannot be predicted, based on the data available from the pre-market 
trials of the drug, there is a high probability of efficacy (versus placebo/no treatment). 
 
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 Vyvgart treatments have been met. Therefore, we decided that the Plan has 
to pre-approve Vyvgart (efgartigimod alfa-fcab) treatments.  
 
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 a tetanus, diphtheria toxoids and acellular pertussis (Tdap) 
vaccine (90715) and administration (96372) provided on December 20, 2021. 
 
You asked the Plan to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and 
administration. You say that you were told this would be covered. The Plan denied your request. The Plan says 
coverage of this vaccine is the responsibility of your prescription drug plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus, diphtheria 
toxoids and acellular pertussis (Tdap) vaccine and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a tetanus, 
diphtheria toxoids and acellular pertussis (Tdap) vaccine and administration. Therefore, we decided that the 
Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and 
administration (96372) provided on December 20, 2021.  
 Benefits for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and administration 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on August 31, 2021. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not covered by Medicare Part A or Part B. 
 
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 pay for self-administered drugs received 
on August 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 14, 2021, to December 13, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nursing or therapy needed. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there no identifiable skilled nursing service 
needs. There were no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or 
therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service criteria for 
an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 14, 2021, to 
December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a cardiac contractility modulation 
(CCM) device. 
 
You asked the Plan to pre-approve the CCM procedure. You say that this procedure should be approved as it is 
medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says there is not 
sufficient evidence in the literature to support that this treatment is necessary. 
 
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 CCM procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found an exhaustive review of the current medical literature pertaining to the CCM system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical 
trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional 
capacity.  
 While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. At the current time, the CCM system is not considered to be medically necessary in this patient. 
 
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 CCM procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a cardiac contractility modulation (CCM) device.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for mobile imaging services provided on April 23, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim did not have the appropriate Place of Service (POS) code. Maximus
overturned the Plans denial. The Plan requested a reopen and demonstrated that the claim was billed with place
of service 31 (facility place of service). Based on Medicare billing guidelines, POS code 31 should be used for
services provided to patients in a Part A covered skilled nursing facility stay. POS code 32 is used for services
provided to patients in a non-covered stay. The records show the enrollee was not in a approved Part A covered
stay on the date of service billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate POS code.
In this case, it has been confirmed that the incorrect POS code was submitted on this claim as the enrollee was
not in a covered SNF stay. Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for mobile imaging services provided on April 23, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a sleep study provided on November 1, 2021. 
 
You asked the Plan to waive the copayment for a sleep study. You say that there was no doctor visit on this 
day. You also say that you only went to the facility to pick up the equipment in the parking lot. The Plan denied 
your request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 provide medical records to confirm what services took place on 
November 1, 2021. Without medical records we are unable to determine if the cost share applied is correct. 
Therefore, we decided that the Plan has to waive the copayment for a sleep study provided on November 1, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided July 22, 
2021. 
 
You asked the Plan to pay for the diagnostic service. You say that this claim was improperly denied. Based on 
CPT and/or CMS guidelines, a provider who prepares a separately identifiable interpretation which contributes 
to the diagnosis and treatment of a patient is entitled to payment. The Plan denied your request. The Plan says 
service paid to another provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the radiologic examination, chest 
(71045) provided July 22, 2021. have been met. the Plan made multiple attempts to obtain medical records and 
supporting documentation from the provider, without success. Therefore, we decided that the Plan does not 
have to pay for the radiologic examination, chest (71045) provided July 22, 2021.