Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide (HHA) services provided on February 
24, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the HHA services. The Plan denied your request. The Plan says the services were 
rendered by a non-network provider. The Plan also says that the services were 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 
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 home health aide (HHA) services provided on 
February 24, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns - porcelain fused to high noble metal (D2750) 
provided March 1 and March 30, 2021. 
 
You asked the Plan to pay for the crowns. You say that you would like the Plan to pay their share of the cost 
for the services. The Plan denied your request. The Plan says the provider who rendered the services has opted 
out of Medicare, and therefore the services are not covered. 
 
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. The Plan covers the crowns 
when the services are rendered by a network provider. 
 
We looked at the file and Medicare rules. The requested provider in this case has opted out of Medicare and 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 pay for these 
items/services. Based on this information, we decided that the Plan's rules for coverage of the crowns have not 
been met. Therefore, we decided that the Plan does not have to pay for the crowns - porcelain fused to high 
noble metal (D2750) provided March 1 and March 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says transportation was not 
provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 26, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 26, 2020. 
 
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says in most cases, care 
received from an out-of-network provider will not be covered, with the following three exceptions: emergency 
care or urgently needed services, Medicare covered medical care that the providers in our network cannot 
provide, and dialysis services at a Medicare certified dialysis facility when you are temporarily outside the 
plan's service area. A prior authorization is required if you are seeking non-emergency 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physical therapy. 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 physical therapy provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital consultation (99254) provided on July 
31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the consultation. You say that this physician provided a medically necessary 
service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 inpatient hospital consultation (99254) 
provided on July 31, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine you received on July 30, 2021. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered 
benefit under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on July 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiation treatment delivery (77401), the therapeutic 
radiology simulation-aided field setting (77280), and the ultrasonic guidance for placement of radiation therapy 
fields (G6001) rendered by the out-of-network (OON) provider on June 8, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 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 radiation treatment delivery (77401), the therapeutic radiology simulation-
aided field setting (77280), and the ultrasonic guidance for placement of radiation therapy fields (G6001) 
rendered by the out-of-network (OON) provider on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lateral exostosis removal (D7471). 
 
You asked the Plan to pre-approve the lateral exostosis removal (D7471). 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 
lateral exostosis removal (D7471).
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 the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that she is not currently receiving but 
that would be available at the LTACH 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a cardiology visit. You say that you were told this provider can treat you. 
The Plan denied your request. The Plan says this is available 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 
a cardiology visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) and guided tissue 
regeneration (D4266) for tooth #17. 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services are not covered by the Plan's dental 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 a 
bone replacement graft (D7953) and guided tissue regeneration (D4266) for tooth #17.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services received on May 27, 2021. 
 
You asked the Plan to pay for the services. You say that you were informed that you would only be responsible 
for 40% of the cost. The Plan denied your request. The Plan says the provider opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visit 
services received on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 LTACH services.
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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, LTACH services will be considered not medically 
necessary as transfer would not be clinically advantageous. Transfer may be considered when the enrollee is 
more stable and treatment has completed. 
 
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 pre-approve computer-assisted surgical navigational procedure for 
bone procedures (identified with code 20985) and surgical techniques requiring use of robotic surgical system 
(identified with code S2900). 
 
You asked the Plan to pre-approve computer-assisted surgical navigational procedure for bone procedures and 
surgical techniques requiring use of robotic surgical system. 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 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 computer-assisted surgical navigational 
procedure for bone procedures and surgical techniques requiring use of robotic surgical system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for bilateral primary osteoarthritis of the hip. The 
enrollee presented with left hip pain for greater than one year. Pain is rated as 9 out of 10 and is stabbing, 
radiating, aching, throbbing, and weakness. Associated symptoms of back pain and weakness is noted. The 
enrollee's exam reveals right hip/thigh abnormal range of motion. The enrollee notes two weeks benefit with 
the cortisone injection. While the enrollee does meet criteria for the total hip arthroplasty approved by the Plan, 
the associated request for computer-assisted surgical navigational procedure for bone procedures is not 
supported. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the 
request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. The surgical techniques requiring use of 
robotic surgical system identified with code S2900 is non-covered. This code has a status code of ?I?. This 
means that this code is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of computer-assisted surgical navigational procedure for bone procedures and surgical 
techniques requiring use of robotic surgical system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve computer-assisted surgical navigational procedure for bone procedures (identified with 
code 20985) and surgical techniques requiring use of robotic surgical system (identified with code S2900).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve percutaneous vertebral augmentation. 
 You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that you need this procedure 
for back pain and broken vertebrae. The Plan denied your request. The Plan says that the requested services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation 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 percutaneous vertebral augmentation. 
Our reviewer says that the documentation does support that the requested services are medically reasonable and 
necessary. Our physician reviewer found you have thoracic and lumbar back pain. Your magnetic resonance 
imaging (MRI) shows "Fracture of the T9 vertebra with edema signal in the central vertebral body and inferior 
endplates compatible with an acute-subacute time course (new from the imaging of August 20, 2020). No 
posterior wall involvement or retropulsion. Mild edema signal is noted in the left T9 pedicle without a definite 
fracture. The documentation supports that you 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 percutaneous vertebral augmentation have been met. Therefore, we decided that 
the Plan has to pre-approve percutaneous vertebral augmentation.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment for an outpatient diagnostic sleep study 
provided by on February 25, 2021. 
 
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 this copayment was applied based on the place of service for the study 
and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated 
that Maximus applied the incorrect contract language.  
 
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. Your contract with the Plan clearly says that you must pay a $40 copayment for 
outpatient diagnostic services. Sleep studies are only no charge if the study is performed in the home. This 
study was performed in the hospital. 

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 $40 copayment for a diagnostic sleep study provided on February 25, 2021.