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

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for 
decompression (PILD) (0275T). 
 
You asked the Plan to pre-approve the PILD. You say that you are not able to walk or stand independently. 
You also say that you have a history of three falls in the last six months. 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 the PILD. Our reviewer says that the 
requested PILD is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology. Overall, the peer-reviewed literature finds only modest evidence for efficacy. Further studies are needed to prove the efficacy of this treatment over the gold standard 
surgical procedures. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested percutaneous 
laminotomy/laminectomy for decompression 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 PILD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve percutaneous laminotomy/laminectomy for decompression (PILD) (0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. 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 November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services provided on June 09, 
2022. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that you were not made aware of 
this copayment amount ahead of time. 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 a $35 
copayment for in-network podiatry services. 
 
You have been asked to pay a $35 copayment for the podiatry services. This item/service falls within the in-
network podiatry services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry 
services provided on June 09, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of rigid total contact leg cast provided on January 
10, 2023. 
 
You asked the Plan to pay for application of rigid total contact leg cast. 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 application of rigid total 
contact leg cast provided on January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder. 
 
You asked the Plan to pre-approve the MRI. You say that you need the imaging to see why you are having so 
much pain. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have been referred to orthopedics for 
evaluation prior to ordering the MRI. Medical necessity of MRI right shoulder has not yet been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the shoulder.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on March 16, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that it is the responsibility of the facility to 
obtain a prior authorization. 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 skilled nursing facility 
provided on March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
June 05, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that because polyps were 
removed the copayment should not apply. 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 a $350 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $350 copayment for the diagnostic colonoscopy. This item/service falls within 
the in-network outpatient surgery 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. The records show this was scheduled as a diagnostic colonoscopy and not a 
screening, and the outpatient surgery copayment does apply. Therefore, we decided that the Plan does not have 
to waive the copayment for the diagnostic colonoscopy provided on June 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum-assisted socket system for the enrollee.
You asked the Plan to pre-approve a vacuum-assisted socket system. You say that this item is medically necessary. The Plan denied your request. The Plan says that criteria for coverage has not been met.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a vacuum-assisted socket system. Our Medical Director states that the provided records in this case are inadequate to fully support the need for the vacuum suspension system. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of a vacuum-assisted socket system.
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 vacuum-assisted socket system have not been met. Therefore, we decided that the Plan does not have to pre-approve a vacuum-assisted socket system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management services provided on June 30, 2023. 
 
You asked the Plan to pay for the care management services. You say that the service was medically necessary. 
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 the care management 
services provided on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the tumor treatment field therapy device (E0766), provided from June 7, 2022, to September 26, 2022.
You asked the Plan to pay for the tumor treatment field therapy device. You say that the item should be covered. The Plan denied your request. The Plan says that you do not have a covered diagnosis for this item. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that the enrollee was informed these services were not covered prior to you receiving this item. The Plan is correct in this case and the file indicates you were provided a denial letter for these services on May 20, 2022. Therefore, plan directed care is not applicable in this case.
The Plan must follow Medicare rules. Medicare rules say that the use of TTFT for any indications other than newly diagnosed glioblastoma multiforme (GBM) will be denied as not medically necessary.
We looked at the file and Medicare rules. The file indicates the TTFT is not being requested for GBM. Based on this information, we decided that Medicare rules for coverage of the tumor treatment field therapy device have not been met. Therefore, we decided that the Plan does not have to pay for the tumor treatment field therapy device (E0766), provided from June 7, 2022, to September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management provided on May 24, 2023. 
 
You asked the Plan to pay for the care management. You say that the enrollee was residing in a nursing facility 
when services were provided. 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 the care management 
provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration for the 
denied claim. 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 the laboratory services 
provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit provided on May 12, 2023. 
 
You asked the Plan to pay for a new patient home visit. You say that the services rendered were medically 
necessary. 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 a new patient home visit 
provided on May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on May 02, 
2023. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that this happened in a providers 
office and the copayment should not apply. 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 a $275 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $275 copayment for the arthrocentesis. This item/service falls within the in-
network outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
arthrocentesis provided on May 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82306) provided on January 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not filed in a timely fashion. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until April 10, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for lab services (82306) provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator provided on 
March 12, 2023. 
 
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that this should be fully 
covered since it is a required item. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the osteogenesis stimulator. This item/service falls within the 
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. The total you owe is $724.38 ($3,621.90 allowed amount x 20% 
coinsurance = $724.38). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
osteogenesis stimulator provided on March 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921), and drugs or 
medicaments dispensed in the office for home use (D9630) provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that were advised that you have up to $2,000.00 of 
benefits and you weren't advised of any other stipulations with your coverage. The Plan denied your request. 
The Plan says your benefit for the gingival irrigation - per quadrant $2,000 dollar limit was met. The Plan also 
says that the drugs or medicaments dispensed in the office for home use (D9630) is not a covered expense 
under your plan. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the drugs or medicaments dispensed in 
the office for home use is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for drugs or medicaments dispensed in the office for home use (D9630) provided on March 30, 
2023. 
 
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 gingival irrigation - per quadrant has been exhausted. The Plan has provided 
evidence of having made payments totaling $2,000 towards the cost of dental services in 2023. This included a 
partial payment of $32 towards the dental services in dispute. Therefore, we decided that the Plan does not 
have to pay for gingival irrigation - per quadrant (D4921) provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision care office visit provided on December 6, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the vision care office visit. You say that you were told this provider is in-
network. The Plan denied your request. The Plan says the provider is out-of-network, and 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 EyeMed Vision Care network. 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 vision care office visit 
provided on December 6, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on April 28, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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. The total allowed amount for the DME is $331.60. You are being asked to 
pay $66.32 ($331.60 x 20% = $66.32). Therefore, we decided that the Plan does not have to waive the 
coinsurance for durable medical equipment (DME) provided on April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
January 23, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on January 23, 2023.