Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (D2740) for tooth #30. 
 
You asked the Plan to pre-approve the crown (D2740). The Plan denied your request. The Plan says the service 
is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the 
crown (D2740) for tooth #30.
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 a SNF admission is medically necessary. The 
Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
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 reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that based on the 
documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. You appear unable to participate in skilled 
therapy. Daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of 
care (ex. long term 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided April 2, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99291 is Critical Care, first hour. 
  
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document 
how much time was spent on this service. Based on this information, we decided that Medicare rules for 
coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services (99291) provided April 2, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care and electrocardiogram services provided on 
February 4, 2020. 
 
You asked the Plan to pay for the critical care and electrocardiogram services. You say that you have submitted 
evidence to support that the claim was submitted within the timely filing range. The Plan denied your request. 
The Plan says this claim was not received by the Plan within one calendar year of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the critical care and electrocardiogram services was not filed until March 5, 
2021. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the critical care and electrocardiogram 
services provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism purchased on May 22, 2021, from an 
unspecified furniture company. 
 
You asked the Plan to pay for a seat lift mechanism. You say that the item at issue was necessary because you 
have noticed it is getting harder for you to get up from a chair. The Plan denied your request. The Plan says 
rules for payment have not been met. 
 
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. 
 
Review of the file does not provide sufficient information to verify whether the provider at issue is enrolled in 
the Medicare program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism 
purchased on May 22, 2021, from an unspecified furniture company.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64491, 94490). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the services are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet injections are only covered in the absence of 
untreated radiculopathy. 
 
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 facet joint injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the patient has radicular 
symptoms and has had surgery at the site of the proposed injections. Rules for coverage are not met.  
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64491, 94490).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on January 19, 2021. 
 
You asked the Plan to pay for the head CT interpretation. You say that this should be paid since multiple exams 
were provided on this date of service. The Plan denied your request. The Plan says this was correctly denied as 
mutually exclusive when billed with 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 the 
head CT interpretation 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 the interpretation of the computed 
tomography (CT) scan of the head provided on January 19, 2021.
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 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 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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor for continuous glucose monitor (A9276). 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee monitors their blood glucose six times a day. 
 
The Plan must follow Medicare rules. The rules say that A9276 is not a covered code. 
 
The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sensor for continuous glucose monitor (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier. 
 
You asked the Plan to pre-approve an air purifier. You say that an air purifier is medically necessary. The Plan 
denied your request. The Plan says an air purifier is not covered by Medicare. 
 
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 an air purifier.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 
28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on April 28, 
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (14301, 14302) provided April 8, 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 documentation does not support the billed services. 
 
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 CPT code 14301, 14302 is not supported in the medical record. Specifically, the operative note 
does not include documentation of transplanting of adjacent skin over the wound. Based on this information, 
we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided 
that the Plan does not have to pay for surgical services (14301, 14302) provided April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain 
indications. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has failed 
conservative treatment. A diagnostic facet injection was performed on July 14, 2021, however, there was no 
pain relief. The documentation does not support that the enrollee has a diagnosis/condition that meets criteria 
for the requested services. Based on a lack of information, the procedure cannot be performed. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided to the enrollee on June 25, 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 the enrollee did not have prior authorization for out of network care. 
 
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 wound care provided to the enrollee on June 25, 
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (G0300 x 4). 
 
You asked the Plan to pre-approve home health services. You say that the services were denied because you 
have Parkinson's Disease. You also say that to your knowledge, you do not have Parkinson's. The Plan denied 
your request. The Plan says you are only covered for skilled care in the home, also known as home health 
nursing care. The Plan says that may include intermittent coverage for activities of daily living such as bathing 
but only during the time you are receiving skilled services. The Plan also says that you do not require skilled 
services. 
 
 The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the record shows that your provider 
requested a home health aide for the purpose of assisting you with bathing. The services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve skilled nursing 
visits (G0300 x 4).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $80 copayment charged for emergency room services 
provided on November 23, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says as you are not Medicaid eligible, your copayment of $80 is correct. 
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not interpret 
the Plan contract correctly. 
 
The Plan is correct in this case. 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 $80 copayment for emergency room services if you are not Medicaid eligible. 
The Plan has confirmed you are not Medicaid eligible.

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 $80 copayment charged for emergency room services provided on November 23, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound dressing (A6196, A6252,A6446 amd A4450) 
provided on June 21, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound dressing. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says these services were 
rendered out-of-network, not urgent or emergent or approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound dressing (A6196, A6252,A6446 amd 
A4450) provided on June 21, 2021 by an out-of-network (OON) provider.