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

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (Kyphoplasty) 
(22514, 22515). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for the indicated conditions.  
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that there is 
no trial of bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (Kyphoplasty) (22514, 22515).
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 these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting. Documentation 
does not support that LTACH services are medically appropriate at this time. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on October 6, 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 the services denied correctly as they do not fall 
within 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 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 core 
buildup services (D2950) provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cochlear implant.

You asked the Plan to pre-approve cochlear implant. You say that it is medically necessary. The Plan denied your request. The Plan says cochlear implant is an implanted electronic hearing device, designed to produce useful hearing sensations to a person with serve deafness.

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 cochlear implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case has a diagnosis of bilateral moderate to profound hearing impairment with limited benefit from appropriate hearing or vibrotactile aids.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cochlear implant have not been met. Therefore, we decided that the Plan does not have to pre-approve cochlear implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99202) and x-rays 
(72020, 72040, 72100) provided from March 22, 2023, to April 3, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these chiropractic services are excluded from coverage. 
 
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 provided by a chiropractor (99202) and x-rays (72020, 72040, 
72100) provided from March 22, 2023, to April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state provided on April 18, 
2023. 
 
You asked the Plan to pay for a determination of refractive state. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says refractions are not covered by Medicare and 
therefore the appeal continues to be upheld. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The eye refraction you asked the Plan to pay for are not covered under Medicare. Eye refractions are not 
covered under your Plan benefit either. Therefore, we decided that the Plan does not have to pay for a 
determination of refractive state provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on June 30, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on June 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on June 19, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service March 16, 
2023. 
 You asked the Plan to pay for procedure code 69990. The Plan denied your request. The Plan says payment for 
code 69990 is bundled into payment for code 61781. 
 
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 69990 
is a column II code to column I code 61781. 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 69990 billed for date of service March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a prosthetic leg. You say that you would like to request reconsideration of 
the denied claim and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the provider is out-of-network, and the requested service can be received in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a prosthetic leg to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 04, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. 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 an office visit provided 
on January 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
  You asked the Plan to pre-approve a home ventilator. You say that you are recommending daily, consistent use 
of a volume mechanical ventilation. You also say that a BiPAP with back up rate average volume-assured 
pressure support (AVAPS) is not a reasonable or acceptable alternative for the enrollee.  The Plan denied your 
request. The Plan says the request for a home mechanical ventilator with settings that could be delivered by 
BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. Our physician reviewer found the enrollee has 
multiple comorbidities to support chronic respiratory failure and require BIPAP therapy, as indicated by the 
documentation provided. However, there is no substantial evidence or data to suggest failure of BIPAP or 
BIPAP with average volume-assured pressure support (AVAPS) to support home ventilator.  Our reviewer also 
found that this request does not meet the standard of care or best practice for a home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this device. The Plan 
denied your request. The Plan says the device is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a life alert system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR) panel billed with 
codes 87150, 87798, 87481, 87640, and 87653 for May 30, 2023. 
 
You asked the Plan to pay for a urine PCR panel. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. The pathogens tested in this case were all in the same anatomical 
region and tested by the same amplified probe technique. As such, a single multiplex infectious agent detection 
panel code should have been used in this case. Based on this information, we decided that Medicare rules for 
coverage of a urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for 
a urine polymerase chain reaction (PCR) panel billed with codes 87150, 87798, 87481, 87640, and 87653 for 
May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an acute rehabilitation facility 
to return to prior level of function. The Plan denied your request. The Plan says your request is not medically 
necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall complies with the various documentation requirements for IRF admission, as 
best summarized by the occupational therapy note from October 21, 2023 and the physical medicine and 
rehabilitation note from October 22, 2023. The enrollee's condition is in fact sufficiently complex, and there is 
every reason to expect that they will participate in and benefit from IRF-level services to include at minimum 
physical and occupational therapy, physician oversight of polpharmacy and case manager coordination of any 
additional services that might be needed to make a sustainable return home, as well as avoid preventable 
readmissions to the acute hospital. Therefore, the requested inpatient rehabilitation facility admission is 
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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the outpatient clinic visit. We decided that the Plan 
does not have to waive the copayment for the outpatient clinic visit.  
 
You asked the Plan to waive the copayment for the outpatient clinic visit provided on June 14, 2023. You say 
that you disagree with the facility charge. The Plan says that this cost sharing was charged correctly. 
 We decided that the Plan has to reduce the copayment for the outpatient clinic visit.  
 
You have been asked to pay $44.04 for the outpatient clinic visit. Based on the Plan contract you cannot be 
asked to pay more than a $40 copayment for this service. Therefore, we decided that the Plan has to reduce the 
copayment for the outpatient clinic visit.  
 
We also decided that the Plan does not have to waive the copayment for the outpatient clinic visit. 
 
You are responsible for paying a $40 copayment for the outpatient clinic visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. 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 the outpatient clinic visit. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services due 
to an extensive wound. You also say the enrollee's medical needs are far too complex to be met at a skilled 
nursing facility. The Plan denied your request. The Plan says  admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that 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 Plan. Given there are offered alternatives, LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 11, 2022. 
 
You asked the Plan to pay for the medical services. You say that you believe that the Plan is the enrollees 
primary insurer. The Plan denied your request. The Plan says you have not submitted this claim to the 
enrollee's primary insurer. 
 
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 provided you 
with the name of the enrollee's primary insurer and has directed you to bill that insurer.  To date, it does not 
appear that you have billed the primary insurer, and you have not provided the Plan with a copy of the 
Explanation of Benefits (EOB) from the primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the medical services until the primary insurer has denied the claim for these services. Therefore, 
we decided that the Plan does not have to pay for medical services provided on July 11, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 21, 2022,
and billed under code 76641.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted that based on the Medicare MUE Practitioner Services sheet effective July 1,
2022, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2 indication this is a
date of service edit. The MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022, update. As
the date of service in question is September 21, 2022, the new MUE value of 1 would apply.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid due to an issue with the MUE value of the
code reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the
Plan does not have to pay for lab services provided to the enrollee on September 21, 2022, and billed under
code 76641.