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

 
We decided that the Plan does not have to pre-approve bilateral genicular nerve blocks. 
 
You asked the Plan to pre-approve bilateral genicular nerve blocks. 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 bilateral genicular nerve blocks. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of chronic bilateral knee pain due to primary 
osteoarthritis of knee. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. Therefore, the enrollee does not meet criteria for the requested 
services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral genicular nerve blocks have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bilateral genicular nerve blocks.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve naturopath services (CPT code A9270). 
 
You asked the Plan to pre-approve naturopath services. You say that you need to have treatment covered to 
treat severe sinus issues. The Plan denied your request. The Plan says the services are not covered by Medicare 
or the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of naturopath services have not been met. Medicare guidance says 
naturopath providers are not eligible to provide services to Medicare members. Therefore, we decided that the 
Plan does not have to pre-approve naturopath services (CPT code A9270).
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 LTACH services. You say that LTACH services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and can remain there until ready for discharge to another setting such as in a skilled nursing facility, at 
home with home health services or at home with outpatient therapy. 
 
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 that the enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93355) provided on April 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 93355 
is a column II code to column I code 01926 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (93355) provided on April 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you do not meet criteria for coverage of these services. 
 
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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be administered at the current facility until appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 30, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says CMS shows your 
status as opting out of Original Medicare participation. 
 
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 an office 
visit provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Guardian 3 sensors (CPT code E1399) and Guardian 3 
transmitter (E1399 x7). 
 
You asked the Plan to pre-approve the DME. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. These items or services still do not 
meet the coverage criteria. Therefore, we decided that the Plan does not have to pre-approve Guardian 3 
sensors (CPT code E1399) and Guardian 3 transmitter (E1399 x7).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve overdenture - complete maxillary (code D5863) and 
overdenture - complete mandibular (code D5865). 
 
You asked the Plan to pre-approve overdentures. You say that the enrollee needs stronger acrylic teeth. The 
Plan denied your request. The Plan says that overdentures (code D5863 and D5865) are not covered by your 
supplemental 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 pre-approve 
overdenture - complete maxillary (code D5863) and overdenture - complete mandibular (code D5865).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arterial catheterization or cannulation for sampling, 
monitoring or transfusion coded 36620 provided on October 26, 2021. You asked the Plan to pay for the arterial catheterization or cannulation for sampling, monitoring or 
transfusion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36620 is arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous. 
 
We find that CPT code 36620 is not supported in the medical record. Specifically, this claim was billed by a 
nurse practitioner. This claim needs to be re-billed under the supervising physician. Based on this information, 
we decided that Medicare rules for coverage of the arterial catheterization or cannulation for sampling, 
monitoring or transfusion have not been met. Therefore, we decided that the Plan does not have to pay for the 
arterial catheterization or cannulation for sampling, monitoring or transfusion coded 36620 provided on 
October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete lower denture (D5120). 
 
You asked the Plan to pre-approve the complete lower denture (D5120). You say that your lower denture is not 
staying in even with paste and comes out before finishing a meal. You say that you desperately need implants, 
and you want help with the cost of the denture. The Plan denied your request. The Plan says a lower complete 
denture is only covered once every 5 plan years. 
 
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, you also have a maximum benefit of 
one complete lower denture every 5 plan years. The plan paid for the complete lower denture (D5120) provided 
on May 14, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-
approve the complete lower denture (D5120).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency services provided on January 30, 2022. 
 
You asked the Plan to pay for the emergency services. You say that this claim should be paid. The Plan denied 
your request. The Plan says that the provider of service is not Medicare-eligible. 
 
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's sole rationale for denial is that the provider of service is 
not Medicare-eligible.  However, in your appeal request, you submitted a copy of a letter issued to you by the 
Centers for Medicare and Medicaid Services.  This letter explicitly grants your organization temporary 
Medicare certification during the COVID-19 public health emergency.  The Plan has failed to acknowledge or 
address this letter in any way. The Plan has failed to refute the certification contained within this letter.  The 
burden is on the Plan to prove why its denial was appropriate, and it has failed to do so in this case. Therefore, 
we decided that the Plan has to pay for emergency services provided on January 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99211), chemotherapy administration 
(96413), dexamethasone sodium phosphate (J1100), additional sequential infusion (96367), granisetron 
(J1626), and injection (96375) provided on February 10, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you have confirmed that the provider in this 
case is in network. You also say that the services should be covered. The Plan denied your request. The Plan 
says the drugs are not approved 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 pay for the outpatient services. Our reviewer says 
that service is not medically necessary. Our physician reviewer found there are no notes attached which 
summarize the diagnosis code and previous treatment. The documentation does not support that this is for 
relapse following complete or partial response or stable disease with primary treatment or that this is 
subsequent therapy for small cell lung cancer. 
 
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 outpatient services have not been met. Specifically, the documentation does 
not support this is for relapse following complete or partial response or stable disease with primary treatment or 
that this is subsequent therapy for the enrollees diagnosis. Additionally, while the record shows that Opdivo 
was covered, the plan is correct to deny the rest because the criteria for use of the drug are not met. Therefore, 
we decided that the Plan does not have to pay for the office visit (99211), chemotherapy administration 
(96413), dexamethasone sodium phosphate (J1100), additional sequential infusion (96367), granisetron 
(J1626), and injection (96375) provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on December 22, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99214) provided on December 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive this cost share.
You asked the Plan to waive this cost share. You say that you should only have to pay the emergency room
copayment. The Plan denied your request. The Plan says the emergency room copayment is for the facility and
is an outpatient service. Physicians can bill for services provided during outpatient facility visits. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $30 copayment for specialist services.
When you visit the emergency room, the $90 copayment encompasses the facility charges. Physicians are
permitted to provide treatment and submit a claim for payment of that treatment as this is an outpatient setting.
Unless you are admitted as an inpatient to the hospital, these separate copayments can apply. Therefore, we
decided that the Plan does not have waive the cost share for specialist services provided on November 10,
2021, and November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services rendered by an OON 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 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 laboratory 
services provided on February 10, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lightspeed front castors (CPT code K0108 x2), 
aluminum side guards (K0108), and solid seat insert (K0108). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. Medicare guidance says items such as 
a solid seat insert or wheel casters are already included in the wheelchair itself and cannot be billed for 
separately. Items such as aluminum sideguards do not serve a medical purpose and are not covered as a 
medically necessary item. Therefore, we decided that the Plan does not have to pre-approve lightspeed front 
castors (CPT code K0108 x2), aluminum side guards (K0108), and solid seat insert (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the 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 bone marrow aspirate. 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 specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for your medical condition as discussed above. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested bone marrow aspirate in the setting of spinal fusion surgery, in this case, 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 the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right femoral/obturator nerve block. 
 
You asked the Plan to pre-approve nerve block. You say that you received a similar procedure that helped 
tremendously. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because this procedure is experimental/investigational. 
 
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 nerve block. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found your treating physician requested the incorrect procedure code for this procedure. Medicare 
guidelines state that an incorrect code cannot be covered if there is an appropriate code for the service. The 
health plan would approve the appropriate code for the procedure if requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right femoral/obturator nerve block.