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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not ready to be discharged home. The 
Plan denied your request. The Plan says the enrollee no longer requires daily skilled services as an inpatient in 
a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous nephrolithotomy (50080) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a percutaneous nephrolithotomy with an out-of-network provider. You say 
that you want the service to be approved. The Plan denied your request. The Plan says the requested service is 
available 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 percutaneous nephrolithotomy (50080) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seals (L5999). 
 
You asked the Plan to pre-approve the seals. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that separate billing of integrated gaskets or seals is 
unbundling. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the seals have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
seals (L5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the service should be covered. The Plan 
denied your request. The Plan says there is no indication the enrollee is in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a CMS approved CED study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a leadless pacemaker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 94 office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve 94 office visits 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 
94 office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
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. 
 
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 in this case. Our physician reviewer found that 
the requested home ventilator is prescribed in the average volume-assured pressure support-automated 
expiratory positive airway pressure (AVAPS-AE) mode, which can be provided with BiPAP. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 continued use of a home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is medically necessary that the enrollee continues 
receiving care at Creekside Village at this time. The Plan denied your request. The Plan says the enrollee no 
longer requires skilled services on a daily inpatient basis and the continuation of a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on October. 22, 2022.
You asked the Plan to pay for this testing. 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 provided the Dex-Z-Code registry page showing code ZBB9S is not a valid code for Medicare purposes.
The Plan is correct in in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, code ZBB9S is not a valid Dex-Z code for Medicare claims. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on October. 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve oncology care. You say that you did not like the provider that was 
previously assisting you. The Plan denied your request. The Plan says this provider is out-of-network with the 
Plan and you can be treated within the Plan 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 
oncology care 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 procedure codes A4550 and S9089 billed for date of service 
February 8, 2023. 
 
You asked the Plan to pay for procedure codes A4550 and S9089. You say that you have filed and refiled with 
everything that was needed including where you paid. The Plan denied your request. The Plan says procedure 
codes 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 procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. We find that procedure code S9089 has a Status Indicator of I 
on the Physician Fee Schedule. This means that procedure code S9089 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A4550 and S9089 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4550 and 
S9089 billed for date of service February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee and rigid dressing. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a microprocessor knee and rigid dressing are 
covered when specific criteria 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 services are medically necessary. Our physician reviewer found the submitted records support that the 
enrollee has K3 functional level potential and has specific needs for the requested knee and other components. 
The requested services are the standard of care for above-knee amputee ambulators and are reasonable and 
medically necessary for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a microprocessor knee and rigid dressing.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal paracentesis and the infusion services 
provided on August 31, 2022, by an OON provider.  
 
You asked the Plan to pay for the abdominal paracentesis and the infusion services. You say that you are 
requesting reconsideration due to medical necessity. 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 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 abdominal paracentesis and the infusion 
services provided on August 31, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision or destruction of intranasal lesion. 
 
You asked the Plan to pre-approve excision or destruction of intranasal lesion. You say that this is medically 
necessary. 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 pre-approve excision or destruction of intranasal 
lesion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that the enrollee has allergic rhinitis 
and sinusitis. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of 
the requested service versus standard therapies. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excision or destruction of intranasal lesion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve excision or destruction of intranasal lesion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have 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 inpatient rehabilitation with 
physician management and intensive therapy services. The Plan denied your request. The Plan says ongoing 
skilled care can be provided in an alternative setting. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has chronic functional loss and is very near their baseline function. The 
enrollee does not require intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E2611 billed for June 10, 2022. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for procedure code E2611 billed for June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each oxygen concentrator provided on 
August 12, 2022, to December 12, 2022. 
 
You asked the Plan to waive the coinsurance for each oxygen concentrator. You say that you believe you are 
being over-charged for this equipment. The Plan denied your request. The Plan says this cost sharing was 
charged 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 20% 
coinsurance for in-network durable medical equipment and related supplies.  
You have been asked to pay 20% coinsurance for each oxygen concentrator. This item/service falls within the 
in-network durable medical equipment and related 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. You are being asked to pay $30.23 each month, 
which is 20% coinsurance of the allowed amount for each oxygen concentrator ($151.15 allowed amount x 
20% coinsurance = $30.23). Therefore, we decided that the Plan does not have to waive the coinsurance for 
each oxygen concentrator provided on August 12, 2022, to December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested pontic- porcelain/ceramic (code D6245). 
 
You asked the Plan to pre-approve code D6245. You say that the patient needs a bridge from tooth 9-11. The 
Plan denied your request. The Plan says pontics are not covered under the patient's 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 pre-approve the 
requested pontic- porcelain/ceramic (code D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression equipment provided on 
December 1, 2022, by an OON provider.  
 
You asked the Plan to pay for the pneumatic compression. You say that the enrollee's provider prescribed this 
equipment. 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 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 pneumatic compression equipment provided 
on December 1, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 23, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says that the provider did not submit any evidence that they have been contacting the member before shipping additional supplies. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.
We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the supplies being dispensed. Based on this information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 23, 2022.