Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation and related services provided on 
April 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. 
Studies completed say that this procedure does not improve outcomes compared to standard treatment of 
sacroiliac joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or 
pulsed radiofrequency, is considered investigational and therefore, not medically 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 services have not been met. As the primary procedure is considered not 
medically reasonable and necessary, the related services are also considered not medically reasonable and 
necessary. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation and related 
services provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received on June 18, 2021. 
 
You asked the Plan to pay for the services. You say that you were not told that these services would not be 
covered. The Plan denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services you received on June 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0428) provided on May 4, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation services. You say that the services 
should be covered as it would cause a financial burden. The Plan denied your request. The Plan says the 
copayment charged is less than the contract states and was applied correctly. 
 
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 $325 
copayment for Ambulance services.  

You have been asked to pay a $293.88 copayment for ambulance transportation services which is less than 
$325. 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 ambulance transportation services (A0425, 
A0428) provided on May 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a colonoscopy to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 colonoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 14, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application of a modality to 1 or more areas; electrical 
stimulation (unattended) (CPT code 97014) provided to the enrollee on February 12, 2021. 
 
You asked the Plan to pay for the service. You say that you are in-network. The Plan denied your request. The 
Plan says you are not in-network and the service are not covered by the Health Plan or Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare guidance says CPT code 97014 has a status code of "I". You can find this guidance in the Year 
National Physician Fee Schedule Relative Value File January 2021 Release. Medicare guidance says status 
code "I" is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, 
these services. Based on this information, we decided that Medicare rules for coverage of the service have not 
been met. Therefore, we decided that the Plan does not have to pay for application of a modality to 1 or more 
areas; electrical stimulation (unattended) (CPT code 97014) provided to the enrollee on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the requested services. You say that your activities of daily living are 
significantly affected. The Plan denied your request. The Plan says the effectiveness has not been demonstrated 
in peer-reviewed literature. 
 
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 the requested services. Our physician 
reviewer found that sacral lateral nerve branch blocks and/or ablations for the diagnosis or treatment of 
sacroiliac joint mediated pain is considered experimental and investigational. Studies show that this procedure 
does not improve outcomes compared to standard treatment of sacroiliac joint pain. The review has determined 
that the requested services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from 
January 4, 2021, to April 10, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 from 
January 4, 2021, to April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for scaling in presence of generalized moderate or severe gingival 
inflammation, full mouth, after oral evaluation (D4346) provided January 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told there would not be additional 
charges for the service and everything was covered by the insurance. You were very surprised that you 
received a bill for $184.60. Please help you to not pay this amount. The Plan denied your request. The Plan 
says that the services is not covered when patient has had prior treatment for periodontitis. 
 
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 provider who rendered the services is a contracted provider. The Plan contract does not indicate that this 
service would not be covered. Under Medicare rules, this means the dental services is considered approved by 
the Plan. Therefore, we decided that the Plan has to pay for scaling in presence of generalized moderate or 
severe gingival inflammation, full mouth, after oral evaluation (D4346) provided January 27, 2021.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that it is felt that this ramp is needed to allow 
the enrollee to get outside into the yard in order to be able to spend time supervised by family members. It is 
felt this will improve his quality of life. The Plan denied your request. The Plan says exterior modifications are 
limited to one ingress/egress routes, into and out of the home, and the member has an existing exterior access 
modification to the garage in place. This is based on the State of Rhode Island's Executive Office of Health and 
Human Services criteria. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, Medicare 
does not cover equipment for use outside the home. The Medicaid criteria cited by the Plan are not within 
Maximus' jurisdiction to review. Therefore, we decided that the Plan does not have to pre-approve a wheelchair 
ramp.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin D testing (82306) provided on June 8, 2021. 
 
You asked the Plan to pay for vitamin D testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare generally considers vitamin assay 
panels (more than one vitamin assay) a screening procedure and therefore, non-covered. The rules also say that 
limited diagnosis codes support medical necessity and provide coverage for procedures codes 82306 and 
82652.  
 
We looked at the file and Medicare rules. The billed diagnosis codes, I10 and E78.00, do not support medical 
necessity for the testing at issue. Based on this information, we decided that Medicare rules for coverage of 
vitamin D testing have not been met. Therefore, we decided that the Plan does not have to pay for vitamin D 
testing (82306) provided on June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional physical therapy visits. You say that you would like 
reconsideration because the member requires skilled therapy to restore their prior level of function utilizing the 
treatment and modalities described in this plan of care. The Plan denied your request. The Plan says the 
documentation does not support continued physical therapy services. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the requested services are not part of a 
maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the member's current condition or to prevent or slow 
further deterioration. 
 
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 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (41899) provided December 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the procedure 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 pay for dental 
services (41899) provided December 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a sleep study performed in a sleep lab with 
continuous airway pressure (95811) provided on June 3, 2021. 
 
You asked the Plan to waive the coinsurance for a sleep study. You say that the coinsurance should be waived 
because you were told there would be no charge and you cannot afford the bill. The Plan denied your request. 
The Plan says the correct cost-share was applied to the claim. 
 
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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a 20% coinsurance for a sleep study (Allowed Amount = $897.41  20% = 
$179.48). Sleep studies 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 coinsurance for a sleep study performed in a 
sleep lab with continuous airway pressure (95811) provided on June 3, 2021.  
 
Your complaint about being told there would be no charge is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee does not need a skilled nurse to make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer 
found the documentation does not support that the enrollee requires additional skilled nursing services to 
provide treatment, care, and/or services in order to improve the enrollee's condition or perform a maintenance 
program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
19, 2021, to June 22, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford to pay 
for the services and were unaware of the copay as you are new to the Plan. The Plan denied your request. The 
Plan says the copayment applied correctly based on the days admitted.  
 
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 $275 
copayment per day for days 1-5 of inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for 3 days of inpatient hospital care ($275 x 3 = $825). 
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 inpatient hospital care provided from June 19, 2021, to June 
22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tooth extraction (D7210) provided by an OON 
provider. 
 
You asked the Plan to pre-approve a tooth extraction. You say that you have seen this dentist for many years, 
and you wish to continue. The Plan denied your request. The Plan says services performed by an OON provider 
are not covered because your healthcare plan does not have OON benefits. 
 
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 a tooth 
extraction when the services are obtained by an in-network provider.  
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve a tooth extraction (D7210) provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi (durvalumab) injection. 
 
You asked the Plan to pre-approve Imfinzi injection. You say that the requested drug in medically necessary. 
The Plan denied your request. The Plan says the requested drug is not approved by the Food and Drug 
Administration (FDA) for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi injection. Our reviewer says 
that the Imfinzi injection is not medically necessary. Our physician reviewer found the requested drug is not 
approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. The reviewer found the use 
is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal (see appendix for list of CMS-approved journals) either. Therefore, the reviewer found that the 
requested drug 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 Imfinzi injection have not been met. Specifically, the requested drug is not 
FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve 
Imfinzi (durvalumab) injection.