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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the L5-S1 facet. 
 
You asked the Plan to pre-approve RFA. You say that you are in extreme pain and must have this procedure. 
The Plan denied your request. The Plan says facet joint procedures performed after anterior lumbar interbody 
fusion (ALIF) are considered not reasonable and necessary and will be denied. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint procedures performed after anterior 
lumbar interbody fusion (ALIF) surgery are considered 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 RFA. Our reviewer says that you do not 
meet criteria for the requested RFA. Our physician reviewer found you have a diagnosis of lumbar spondylosis 
and fusion to L5-S1. You have undergone L5-S1 facet RFA in the past. The most recent was in May of 2022 
which provided over 80% pain relief until recently, but your pain has returned. Medicare excludes RFA 
performed at the site of a prior fusion. Therefore, this request is not medically reasonable and 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) of the L5-S1 facet.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 25, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on July 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 12001, 99283, 99284, 99285 rendered on 
August 1, 2022. 
 You asked the Plan to pay for procedure codes 12001, 99283, 99284, 99285. You say that these charges are 
prior to the enrollee being discharged from the hospital and prior to the hospice admission. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure codes 12001, 99283, 99284, 99285 rendered on 
August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of an implant body (D6100) and 
the surgical placement of an implant body; endosteal implant (D6010) to be rendered by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under the 
supplemental dental policy.  
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical 
removal of an implant body (D6100) and the surgical placement of an implant body; endosteal implant 
(D6010) to be rendered by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that additional visits are needed to complete 
treatment. The Plan denied your request. The Plan says the requested services are not medically reasonable and 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy (PT) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five outpatient clinic visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the clinic visits. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services can be provided 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 
five outpatient clinic visits to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an MRI and medical supply provided on 
December 20, 2022. 
 
You asked the Plan to waive the cost for an MRI and medical supply. You say that your copayment should only 
be $140, and that amount applied to the $1,000 deductible. 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. Your 
contract with the Plan says that there is $1,000 deductible which applies to an MRI. 
 
 
  You have been asked to pay $410.59 for an MRI and medical supplies. This total includes a $404.99 deductible 
for the MRI and $5.60 coinsurance for the chemical agent used for the MRI. These items/services fall within 
the outpatient diagnostic tests benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is $1,000 deductible which applies to an MRI. This cost sharing is a contractual 
obligation that had not been met at the time an MRI and medical supply was received on December 20, 2022. 
Therefore, we decided that the Plan does not have to waive the cost for an MRI and medical supply provided 
on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression sleeves identified with code A6549. 
 
You asked the Plan to pre-approve the compression sleeves. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says the compression sleeves requested are not a 
covered benefit.  
  
 
 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
sleeves identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive series of radiographic images (D0210) 
provided by on February 13, 2023. 
 
You asked the Plan to pay for the dental service. You say that you did not know that the dental service would 
not be covered, and you never received and notice of change from the Plan. The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. Also, it was verified that an 
annual notice of change was sent to you on September 17, 2022. 
 
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, certain limitations apply. The record 
shows the Plan paid for the panoramic radiographic image (D0330) on February 13, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of February 13, 2023. Therefore, 
we decided that the Plan does not have to pay for the comprehensive series of radiographic images (D0210) 
provided by on February 13, 2023.  
 
Your complaint about your experience with the provider is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), the post and core addition to crown 
(D2952), the endodontic therapy (D3310), and the crown lengthening (D4249) for tooth #9 provided by an out-
of-network provider on September 9, 2022, November 1, 2022, December 1, 2022, and January 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740), the post and core addition to crown (D2952), the endodontic therapy (D3310), and 
the crown lengthening (D4249) for tooth #9 provided by an out-of-network provider on September 9, 2022, 
November 1, 2022, December 1, 2022, and January 17, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  skilled nursing facility (SNF) services. 

You asked the Plan to provide coverage for  SNF services. The Plan denied your request. The Plan says the 100-day benefit had been exhausted. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided documentation to show 100 days had been exhausted. 

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from July 8, 2022, through January 24, 2023. The Plan has covered 100 days of SNF care. Although you may have needed care at the time of the appeal, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to provide coverage for  skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested stockings are 
not a covered benefit.  
  
 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the lumbar facet joint injections provided on January 5, 2023. 
 
You asked the Plan to pay the injections. The Plan denied your request. The Plan says the lumbar facet joint 
injections 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 pay for the injections. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that there was no documentation of 
moderate to severe chronic low back pain or a minimum of 3 months of non-invasive or conservative 
management. There is no documented evaluation of untreated radiculopathy, neurogenic claudication, or any 
evaluation for non-facet pathology. Also, there are no radiology studies that could explain the source of the 
enrollees pain. Therefore, the enrollee did not meet the LCD coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar facet joint injections provided on January 5, 2023.
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 the services are medically necessary for 
the enrollee to receive the care needed for their complex medical conditions. The Plan denied your request. The 
Plan says the enrollee is receiving the care needed and is currently unstable for transfer to an LTACH.  
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785-26 and 95861-26-59 billed for date 
of services December 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the codes are not substantiated by the clinical documentation. 
 
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 find that CPT codes 51785-26 and 95861-26-59 are not supported in the medical record. The records do not 
include a formal report of the nerve testing, 95861. The records do not include a diagnostic electromyography, 
51875. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 51785-26 and 95861-
26-59 billed for date of services December 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE). 
 
You asked the Plan to pre-approve wireless capsule endoscopy. You say that the enrollee is losing blood and 
you are not sure where the blood is coming from. The Plan denied your request. The Plan says the record does 
not show that there is a concern for occult gastrointestinal (GI) bleeding, or that esophagogastroduodenoscopy 
(EGD) and colonoscopy failed to reveal a source of bleeding. 
 
The Plan follows Medicare rules. Medicare rules state that WCE is only covered under certain indications and 
some limitations apply. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the enrollee does not meet criteria for a wireless capsule endoscopy. Our physician reviewer 
found the enrollee reportedly has microcytic anemia, but no laboratory results were provided to corroborate 
either iron deficiency, gastrointestinal blood loss, nor the acuity/extend of the enrollee's anemia. In the absence 
of esophagogastroduodenoscopy (EGD) or colonoscopy findings, nor records to meet any other Medicare 
criteria, the medical appropriateness and necessity of a wireless capsule endoscopy is not supported 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 wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (WCE).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on February 17, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport, and ground 
mileage. You say that this service was provided to the enrollee due to medical necessity. The Plan denied your 
request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport, and ground mileage. Our reviewer says that the ambulance transport services were 
not medically necessary. Our physician reviewer found the record indicates that the enrollee was transported 
from the hospital to a skilled nursing facility via stretcher.  The record does not indicate that the enrollee's clinical condition was such that other methods of transport, such 
as stretcher van, were contraindicated or that the expertise, services and lifesaving and life-sustaining 
equipment that only a fully equipped ambulance can provider was required. The record provided does not 
establish that medical necessity and reasonableness, as defined by Medicare rules, of the required service. 
 
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 ambulance service, basic life support, non-emergency transport, and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on February 17, 2023.