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

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on January 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service.  Therefore, we decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-
network (OON) provider on January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery (66984) rendered by the out-of-network 
(OON) provider on October 21, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the cataract surgery (66984) rendered by the out-of-network (OON) provider on 
October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glcyosylated hemoglobin testing rendered on December 
3, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, glcyosylated hemoglobin, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the glcyosylated hemoglobin testing rendered on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on January 13, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. 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 it was determined 
these services were 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 Home Health 
Services provided on January 13, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on February 14, 2022, by 
an OON provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that the enrollee came for the visit after have a 
procedure done. 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 an outpatient clinic visit provided on February 14, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services billed for date of service August 
6, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that there is no evidence that the patient 
was an inpatient at the time of these services. The Plan denied your request. The Plan says these services are 
not payable on an outpatient basis. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 32100. This code is listed with a status indicator of 
C on Addendum B of the 2021 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. 
  
 Therefore, we decided that the Plan does not have to pay for outpatient hospital services billed for date of 
service August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the Inogen portable oxygen concentrator 
purchased on December 9, 2021. 
 
You asked the Plan to provide reimbursement for the portable concentrator. You say that you understood that 
durable medical equipment was covered under your Plan. You need this to maintain your oxygen levels when 
you are away from your home concentrator. The Plan denied your request. The Plan says this provider is not a 
Medicare-enrolled equipment provider. This means that the services were correctly denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. In addition, the purchase of oxygen equipment is not covered by 
Medicare, as it is covered on a rental basis only.  
 
This equipment was purchased outright and not provided as a rental. Review of the file and Medicare records 
indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to provide reimbursement for the Inogen portable oxygen 
concentrator purchased on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care services (92133, 92012) provided on November 
18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON vision care. You say that these services were necessary and appropriate. 
The Plan denied your request. The Plan says out-of-network services are covered only in certain limited 
circumstances. The care provided was not urgent or emergent, nor was it pre-approved or referred by an in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider 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 vision care services (92133, 92012) provided on 
November 18, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with polyp 
removal provided on January 4, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you had a positive 
cologuard test which was why the colonoscopy was done. You also say that after 11 years since your last 
colonoscopy this should have resulted in a preventive service. The Plan denied your request. The Plan says you 
have been 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 $300 
copayment for in-network outpatient surgery at an ambulatory surgical center.  
 
 The medical record shows you had a diagnostic colonoscopy with polyp removal. Therefore, a cost sharing 
amount applies. You have been asked to pay a $300 copayment for a diagnostic colonoscopy. A diagnostic 
colonoscopy 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 a 
diagnostic colonoscopy with polyp removal provided on January 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
30, 2021. 
 
You asked the Plan to pay for procedure code 76705. You say that you do not believe this should be bundled. 
The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.  
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service December 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 10, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum on December 3, 2021, so no additional non-Medicare covered chiropractic services are eligible 
for coverage after that date. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (code 98943) and the electrical stimulation (code G0283) provided by a 
chiropractor on December 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for an 
LTACH admission The Plan denied your request. The Plan says all services that would be provided in the 
LTACH are being provided in the current health care setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara (J3357). 
 
You asked the Plan to pre-approve Stelara. You say that the enrollee has been on this medication for three 
years. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
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 Stelara (J3357).  
 
Benefits for Stelara 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on July 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 11043, 11046, 10180, 14301, and 15002 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11043 is debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. The definition of code 11046 
is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure). The definition 
of code 10180 is incision and drainage, complex, postoperative wound infection. The definition of code 14301 
is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 
15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar 
(including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 
1% of body area of infants and children. 
 
We find that CPT codes 11043, 11046, 10180, 14301, and 15002 are not supported in the medical record. 
Specifically, there is no documentation of debridement of muscle and/or fascia for the first 20 sq cm or less to 
support code 11043. There is no documentation of debridement of muscle and/or fascia for each additional 20 
sq cm or part thereof to support code 11046. There is no documentation of a complex incision and drainage of a 
postoperative wound infection to support code 10180. There is no documentation of adjacent tissue transfer or 
rearrangement of any area for defects 30.1 sq cm to 60 sq cm to support code 14301. There is no 
documentation of surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or 
scar tissue, or incisional release of scar contracture of the trunk, arms, and legs for the first 100 sq cm to 
support code 15002. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a below-knee alignable system (code L5910, left side). 
 
You asked the Plan to pre-approve below-knee alignable system. You say that this is medically necessary. The 
Plan denied your request. The Plan says that the denial of authorization for this component is correct, because 
there is no documentation that the enrollee will have an alignable base prosthesis on the left side. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 below-knee alignable system. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the preparatory socket is reasonable as the enrollee's limb would be expected to 
change during the initial fitting process and the approved code L5540 refers to a patellar tendon bearing socket 
as opposed to total surface bearing as stated by the 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 below-knee alignable system have been met. Therefore, we decided that the 
Plan has to pre-approve a below-knee alignable system (code L5910, left side).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower extremity prosthesis, endoskeletal 
knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any 
type (CPT code L5856), addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (CPT code L5828), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (CPT 
code L5845), and addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or 
without adjustability (CPT code L5848). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not 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 does not support that the member is a K3 ambulator. There is no indication why an 
upgraded knee/shin system with a microprocessor is required compared with a manual. The requested additions 
are appropriate for a more advanced level ambulatory and therefore are not medically necessary at this time. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control 
feature, swing and stance phase, includes electronic sensor(s), any type (CPT code L5856), addition, 
endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT code L5828), addition, 
endoskeletal, knee-shin system, stance flexion feature, adjustable (CPT code L5845), and addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (CPT 
code L5848).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Panniculectomy.
You asked the Plan to provide coverage for a Panniculectomy. You say that this surgery is medically necessary.
The Plan denied your request. The Plan says the medial records show you are responding to topical treatments.
Maximus administratively overturned the Plans denial because medical records were not included in the case
file. The Plan requested a reopen and submitted the required medical records.
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. The medical records provided do not support the requested surgery is medically necessary. The
records do not reflect on-going treatment of rashes completely resistant to medicated creams or ointments over
several months. Medicare rules for coverage of a Panniculectomy have not been met. Therefore, we decided
that the Plan does not have to provide coverage for a Panniculectomy.