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

We decided that the Plan does not have to pay for the blood bank physician services (86077) provided to the
enrollee on May 23, 2022.
You asked the Plan to pay for the blood bank physician services. You say that this service was medically
necessary and is supported in the medical record. The Plan denied your request. The Plan says that this claim
was submitted with a secondary/manifestation diagnosis code as the primary diagnosis, and therefore was not
submitted in accordance with Medicare guidelines.
The Plan is correct in this case. This claim was filed with a manifestation code as the principal diagnosis code.
Based on this information, we decided that Medicare rules for coverage of the blood bank physician services
have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician
services (86077) provided to the enrollee on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the office visits. You say that the enrollee is requesting to see this provider 
as they have seen them previously. The Plan denied your request. The Plan says authorization has been 
approved with a 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 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 
office visits 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 pay for the vision frames (V2020), single plane lenses (V2100), a
medical eye examination (92004), and fundus photography (92250) provided from December 10, 2021, to
December 28, 2021.
You asked the Plan to pay for these services. You say that you were told by the provider that your charges were
covered by your insurance. The Plan denied your request. The Plan says that part of this claim is a duplicate of
a previously paid claim and was correctly denied. The Plan says that the out-of-network copayment for routine
eye exam covers up to $40. The Plan also says that fundus photography is not covered for routine supplemental
benefits.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. The Plan
contract vision care benefit excludes fundus photography (92250). The Plan contract says that they cover $40
towards a routine eye exam.
We looked at the file and Medicare rules. The file includes evidence that the vision frames and single plane
lenses at issue were reimbursed by the Plan on May 16, 2022. Comparison of the two claims shows these are
exact duplicates. There is no evidence presented to support that the billed vision frames and single plane lenses
were provided twice on the same date. Based on this information, we decided that the Medicare rules for the
vision frames and single plane lenses have not been met.
The record shows that fundus photography is excluded from the Plan vision care benefit. The record also shows
that your medical eye examination was $60, which is $20 more than the $40 allowance ($60 - $40 = $20).
Therefore, we decided that the Plan does not have to pay for the fundus photography (92250) and an additional
$20 towards the medical eye examination (92004).
Therefore, we decided that the Plan does not have to pay for the vision frames (V2020), single plane lenses
(V2100), a medical eye examination (92004), and fundus photography (92250) provided from December 10,
2021, to December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle/foot orthosis to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ankle/foot orthosis. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says network providers are available to render necessary 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ankle/foot orthosis to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that network providers were unable to treat your 
condition effectively. The Plan denied your request. The Plan says network providers are available to render 
necessary 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 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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plan's network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 
physical therapy 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 pay for core buildup services (D2950) provided on November 22, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and were not made aware of the charges. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within your dental benefits. The record indicates that you were 
made away that the core buildup services are not covered under your dental benefits. 
 
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 pay for core 
buildup services (D2950) provided on November 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on March 08, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient mental health 
provided on March 08, 2022.
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 member's current medical condition 
cannot be adequately cared for at a lower level of care. The Plan denied your request. The Plan says member is 
receiving appropriate in-patient acute care and does not require transfer to an LTACH. 
 
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 available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee would benefit from a 
therapeutic CGM. The Plan denied your request. The Plan says the enrollee does not require insulin three or 
more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic CGM.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye surgery provided on April 05, 2022. 
 
You asked the Plan to pay for eye surgery. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for eye surgery provided on 
April 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supply allowance billed on
April 16, 2022.
You asked the Plan to pay this claim. You say that the Plan should cover this item. The Plan denied your
request. The Plan says they were not the primary insurer at the time of service. Maximus overturned the Plans
denial for a lack of documentation to show the primary insurer was contacted. The Plan requested a reopen and
stated that the Medicare eligibility system clearly shows the enrollee had another Plan that was the primary
insurance carrier at the time of service. This Plan, as secondary insurer, has attempted to obtain proof from the
other insurance carrier of their review, but the documentation has not been obtained. The primary insurer
indicated this process can take up to 30 days. Once the secondary insurer receives the primary carrier's
documentation, they will reprocess any balance toward the enrollee's benefit.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are
considered secondary insurers when an enrollee has another type of insurance. The enrollment database clearly
states there was another primary insurer in place. The Plan has met its obligation with regards to coordination
of benefits in its attempt to have the primary carrier provide documentation of their review. Therefore, we
decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided on
April 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology services provided to the enrollee on November
22, 2021.
You asked the Plan to pay for the neurology services. You say that these services should be paid for. The Plan
denied your request. The Plan says that the provider should bill the facility.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that CMS does not
pay any provider or supplier other than the facility or hospital for services furnished to an enrollee. The facility
or hospital must furnish all necessary covered services either directly or under arrangements made with outside
providers. This equipment was brought to the facility for the staff to use in treatment of the enrollee. Payment
for the use of this equipment would have been included under the facility claim. Payment to you for the use of
this equipment is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have
to pay for the neurology services provided to the enrollee on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 2, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 5, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 2, 
2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to hold the enrollee harmless for home infusion services provided from February 
1, 2021, to June 30, 2022. 
 
You asked the Plan to hold the enrollee harmless for the home infusion services. You say that the enrollee is 
being billed incorrectly for these services. The Plan denied your request. The Plan says that this cost sharing 
was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided records to support that these services took place. 
Therefore, we decided that the Plan has to hold the enrollee harmless for the home infusion services provided 
from February 1, 2021, to June 30, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine provided on October 18, 2022. 
 
You asked the Plan to pay for the influenza vaccine. You say that immunizations should be covered 100%. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the influenza vaccine 
provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM sensor kit. You say that you disagree with 
the denial and request reconsideration. The Plan denied your request. The Plan says the enrollee does not 
require three or more insulin injections per day and does not require an insulin pump. The enrollee does not 
meet criteria for approval of the CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14-day CGM sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14-day continuous glucose monitor (CGM) sensor kit.