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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs to be in quarantine because of 
Covid-19. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or 
therapy services on an inpatient basis. 
 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 pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There 
are no identifiable skilled nursing service needs.  Regarding rehabilitation services, the enrollee was at a 
supervision assist level for functional mobility. She required varying assist for activities of daily living. 
Although there are identifiable skilled therapy service needs, she does not require skilled nursing or therapy 
services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient 
basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the drug testing was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
drug testing at issue. We found no exception that would require the Plan to pay for the drug testing. The 
records provided for review do not show that the drug testing was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for the drug testing provided on January 27, 2022, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray provided on September 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the knee x-ray. You say that you are out-of-network, however, the enrollee 
cannot choose which radiologist reads their diagnostic test. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
 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 did not pre-approve the x-
ray. We found no exception that would require the Plan to pay for the x-ray. The records provided for review 
do not show that the x-ray was urgent or emergent. Therefore, we decided that the Plan does not have to pay for 
the knee x-ray provided on September 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on January 19, 2022.  
 
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 waive the copayment for shoulder orthosis (L3670) provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for the shoulder orthosis. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on 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 20% 
coinsurance for Prosthetic devices and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the shoulder orthosis (allowed is $93.56 x 20% = $18.17). 
Shoulder orthosis falls within the Prosthetic devices and related 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 copayment for shoulder orthosis (L3670) provided on December 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for ultrasounds provided on February 10, 
2020. 
 
You asked the Plan to waive the cost-sharing for ultrasounds. You say that you should not have to pay for this 
because you never received the test results and had to go to a different provider to find out what was wrong 
with you. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 
correct. 
 
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 $300 deductible and $10 copayment for in-network ultrasounds. At the time this claim was processed, $39.16 of the 
$300 in-network deductible had been met. The allowed amount of this claim is $536.39, resulting in a 
deductible amount of $260.84 because this amount meets the $300 total in-network deductible for 2020. After 
the deductible is met, the remaining allowed amount of the claim is $275.55, resulting in a $10 copayment. 
Therefore, your total cost-sharing amount is $270.84. 
 
You have been asked to pay $300 deductible and $10 copayment for ultrasounds. Ultrasounds fall 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-sharing for ultrasounds provided on February 10, 2020.  
 
Your complaint regarding not receiving the results of these tests is considered to be a grievance. MAXIMUS 
does not have the jurisdiction to address grievances. Please contact the Plan for more information about your 
grievance.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ezetimibe. 
 
You asked the Plan to pre-approve Ezetimibe. You say that the enrollee is currently on this drug and is stable. 
The Plan denied your request. The Plan says Ezetimibe is a self-administered drug and does not fall under Part 
B coverage. The Plan says that the enrollee does not have pharmacy benefits under this contract. 
 
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 Ezetimibe.  
 
Benefits for Ezetimibe 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eighty-four (84) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips for the rest of the year to attend your dialysis appointments three times a week. The Plan 
denied your request. The Plan says you have exhausted the maximum benefit of 36 one-way trips per year. 
 
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 36 one-way trips per year 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 eighty-four (84) additional routine transportation trips 
(A0120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the continued SNF care is medically 
necessary. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has 
met the plan limits which have been set in the subscriber agreement. 
 
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 November 5, 
2021, through May 22, 2022. 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 pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fluid Flow injection to the right hip provided on May 10, 
2021. 
 
You asked the Plan to pay for the Fluid Flow injection. You say that it is felt that this treatment is helpful and 
should be considered medically necessary. The Plan denied your request. The Plan says this is an experimental 
treatment. 
 
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 pay for the Fluid Flow injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the clinical value and effectiveness of Fluid Flow 
injections in the setting of hip pain have not been demonstrated in the peer-reviewed literature. The medical 
effectiveness of the above therapy has not been verified by scientifically controlled studies. The review has 
determined that the requested Fluid Flow injection in this case 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 Fluid Flow injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the Fluid Flow injection to the right hip provided on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjacent tissue transfer represented by code 14040 and a 
glossectomy represented by code 41150, both billed for date of service June 23, 2021. 
 
You asked the Plan to pay for the adjacent tissue transfer and the glossectomy. You say that the medical 
records provided support the services as billed. The Plan denied your request. The Plan says the procedure 
codes were not supported by the medical records provided. 
 
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 14040 is Adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less. The CPT 
Code Manual definition of code 41150 is glossectomy; composite procedure with resection floor of mouth and 
mandibular resection, without radical neck dissection. 
 
We asked our coder 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 adjacent tissue transfer and the glossectomy. Our 
reviewer says that the codes in dispute are not supported. Our reviewer found the operative report does not describe the removal of all or part of the tongue, as well as part of the jawbone and the tissue of the floor of the 
mouth. Our physician reviewer found that the operative report was unable to be cited, as the procedure 
represented by code 41150 was not documented. Our physician reviewer found that the operative report 
describes advancement flap via underming. CPT guidelines require a secondary defect to be created by the 
surgeon to move tissue and close the primary defect. Procedure code 14040 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the adjacent tissue transfer and the glossectomy have not been met. Therefore, 
we decided that the Plan does not have to pay for an adjacent tissue transfer represented by code 14040 and a 
glossectomy represented by code 41150, both billed for date of service June 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retroperitoneal ultrasound represented by code 76770 and 
billed for date of service October 18, 2021. 
 
You asked the Plan to pay for a retroperitoneal ultrasound. You say that the clinical information provided 
supports the service in dispute. The Plan denied your request. The Plan says the billed services were 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 76770 is Ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation. 
 
We asked our coder 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 a retroperitoneal ultrasound. Our reviewer says that the code 
billed is not supported. Our reviewer found the procedure report documents the right kidney as 10.1 cm and the 
left kidney as 11.1 cm. There is not a mass, stone, or hydronephorsis bilaterally. There was a normal 
examination of the kidneys bilaterally. A complete retroperitoneal ultrasound is not supported and there is a more appropriate code to report the service documented.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a retroperitoneal ultrasound have not been met. Therefore, we decided that the 
Plan does not have to pay for a retroperitoneal ultrasound represented by code 76770 and billed for date of 
service October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery (including elevation of a full 
thickness flap and closure)  one to three contiguous teeth or tooth bounded spaces per quadrant (D4261) and a 
debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant (D6102). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the requested procedure codes are not 
listed and therefore not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
osseous surgery (including elevation of a full thickness flap and closure)  one to three contiguous teeth or 
tooth bounded spaces per quadrant (D4261) and a debridement and osseous contouring of a peri-implant defect 
or defects surrounding a single implant (D6102).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 26, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has 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 did not pre-approve the 
physicians services. 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 physician's services provided on April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. 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 Plan says that the Plan has 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 did not pre-approve the 
services at issue. 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 an office visit provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for hearing aids provided on  
October 6, 2021. 
 
You asked the Plan to pay an additional amount for hearing aids. The Plan denied your request. The Plan says 
you were reimbursed $500 with check # 0007982244 dated January 27, 2022. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has reimbursed you the maximum 
benefit amount of $500 with check number # 0007982244 dated January 27, 2022. Therefore, we decided that 
the Plan does not have to pay an additional amount for hearing aids provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 4, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on October 4, 2021.