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

 
We decided that the Plan does not have to pre-approve the dental service (D2799). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the dental service (D2799) 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 
dental service (D2799).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
egg switches (K0108). 
 
You asked the Plan to pre-approve an expandable controller, harness, and egg switches. The Plan denied your 
request. The Plan says that it is not medically necessary to control the power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is 
medically necessary to control the power options through the joystick. The rules also say that code K0108 must 
not be used for any component or feature of an expandable controller at the time of initial issue. 
 
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 an expandable controller and harness. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you have 
adequate strength to manage the standard controls on the power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and harness have not been met. The requested egg 
switches are not covered as code K0108 must not be used for any component or feature of an expandable 
controller. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), 
harness (E2313), and egg switches (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional office visits with a gynecologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve additional office visits. You say that you would like to see the requested 
provider because you previously had surgery with this doctor. The Plan denied your request. The Plan says you 
must receive your care from an in-network provider (doctor, facility, and other healthcare professionals) when 
available. There are in-network gynecologists available in your area. The Plan also says one visit has been 
approved to allow for transition of care to an in-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 
nine (9) additional office visits with a gynecologist to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May
3, 2022, through May 23, 2022.
You asked the Plan to pay for the home health services. You say that these services were medically necessary.
The Plan denied your request. The Plan says that the type of bill was incorrect. Maximus overturned the Plan's
denial. The Plan requested a reopening based on the fact the claim was submitted with the incorrect type of bill
code. The Plan was correct in this case, the claim was not filed with the correct type of bill code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from May 3, 2022, through May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for out of network lab services provided to the enrollee on August 18, 2022.
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 Plan states these services were ordered by a non-contract provider and sent to a non-contract lab without prior authorization. Maximus overturned the Plans denial for insufficient information regarding the ordering provider. The Plan requested a reopen and stated Maximus did not review the correct information.
The Plan is correct in this case. 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.
Both the ordering provider and the lab are out of network. The enrollee did not have prior authorization for out of network services. The Plan had network providers available who could have provided the services at issue in this appeal. Therefore, we decided that the Plan does not have to pay for out of network lab services provided to the enrollee on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 19, 2022.
You asked the Plan to pay for the bitewing x-rays. 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 Plan's 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 July 13, 2022, when you received a bitewing - single radiographic image (D0270). Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you do not want to lose the progress you 
have made. You say you live an active lifestyle and believe this will severely affect your quality of life. The 
Plan denied your request. The Plan says you would benefit from two additional physical therapy visits for 
transfer to a home exercise program. 
 
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 therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the Plan. You can transition to an 
independent home program with the already approved therapy. Your deficits and functional level do not require 
ongoing formal physical therapy beyond what was already approved. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve the percutaneous vertebral augmentation. You say that the enrollee will 
likely develop thoracolumbar kyphosis requiring multi-level pedicle screw instrumentation in the future. The 
Plan denied your request. The Plan says the request is not medically necessary because the records do not show 
the enrollee has an osteoporotic or malignant compression fracture. 
 
  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 percutaneous vertebral 
augmentation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation of imaging studies showing an 
acute fracture less than 6 weeks old. 
 
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 percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 3, 2022.
You asked the Plan to pay for the lab services. You say that you would like the Plan to make payment on this claim. The Plan denied your request. The Plan says that they have reached out to your other insurance carrier without response.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers.
Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has sent the bill to the primary insurer and requested the Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for the lab services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service October 10, 
2022. 
 You asked the Plan to pay for procedure code 99152. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99152 is bundled into payment for code 45380. 
 
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 99152 
is a column II code to column I code 45380. 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 procedure code 99152 billed for date of service October 10, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation (A0130). 
 
You asked the Plan to pre-approve wheelchair van transportation. You say that you need non-emergency 
transportation to appointments once you are able to go home from the facility you live in, as you cannot walk. 
The Plan denied your request. The Plan says non-emergent transportation is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 
 
 
 The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation (A0130).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on October 21, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says that 
evaluation and management codes are not covered for this specialty or provider type. 
 
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. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for an emergency department 
visit provided on October 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism, electric, any type (E0627) sales tax 
(S9999) purchased December 16, 2022. 
 
You asked the Plan to pay for the power lift assist recliner. You say that you were unable to find a provider that 
could get the seat lift within 30 days, and you had to go through this provider. The Plan denied your request. 
The Plan says the item was purchased from a provider that does not participate with Medicare. 
 
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 and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism, electric, any 
type (E0627) sales tax (S9999) purchased December 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of anemia due to chronic renal insufficiency and low risk 
myelodysplastic syndrome. The record indicates that the enrollee's last hemoglobin is 11.9 mg/dl, improved 
over previous determinations. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved  drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the enrollee does not 
meet criteria for the requested drug. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found that the records show you have back pain and leg weakness. You do not have severe arthritis and are not incapable of rising from a chair. The criteria for 
coverage are not met; therefore, the seat lift mechanism is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gauze, non-impregnated (A6220) provided on 
April 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that wound care supplies are a separately 
billable expense that does not require authorization or referral. The Plan denied your request. The Plan says 
enrollees 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 sterile gauze, non-impregnated (A6220) 
provided on April 29, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 9, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that this claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile specialty absorptive dressing, wound cover 
(A6254) and foam dressing, wound cover, sterile (A6210) provided August 11, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that please reconsider and reprocess this claim. 
The Plan denied your request. The Plan says requested documentation was not received. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Specifically, the documents do not have actual 
proof of delivery nor a signed acceptance of delivery from the enrollee. In addition, no ordering physician 
records, or a standard written order was included. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the sterile specialty absorptive dressing, wound cover (A6254) and foam dressing, wound cover, sterile 
(A6210) provided August 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on October 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the Plan was unable to make a decision timely. 
 
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. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for laboratory services provided 
on October 24, 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.