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

 
We decided that the Plan does not have to pay for outpatient hospital services provided on June 27, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for outpatient hospital services. You say that the provider had a referral. The Plan 
denied your request. The Plan says their original decision to deny payment was correct. 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 outpatient hospital services provided on June 27, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional trips. 
 
You asked the Plan to pre-approve 60 additional trips. You say that you have to go to the dialysis three times a 
week. You also say that you do not have any family that can provide transportation for you to get to dialysis. 
The Plan denied your request. The Plan says you have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 60 additional trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve precision attachment (D6950), implant placement 
(D6010), and implant abutment (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says implant placement and implant abutment has already been exhausted. 
Precision attachment is not a covered service. 
 
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 your benefit for the implant placement and implant abutment was exhausted. Precision attachment is not a covered service.  Therefore, we decided that the Plan does not have to pre-approve precision attachment 
(D6950), implant placement (D6010), and implant abutment (D6057).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve omeprazole. 
 
You asked the Plan to pre-approve omeprazole. You say that that the enrollee suffers from multiple medical 
problems including atrial fibrillation for which they are on chronic anticoagulation, diabetes, and 
gastroesophageal reflux disease. You say that the enrollee has been on omeprazole 40mg daily for many years. 
The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare Part B 
coverage.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve omeprazole.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the cork insert is important to have it for your 
surgery to help level your hips. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on July 6, 
2023. 
 
You asked the Plan to pay for the dental service. You say that this was the only time you had a panoramic film 
on your teeth. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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 an intraoral complete series of radiographic images (D0210) on September 28, 2022; 
therefore, your benefit for the requested item or service was exhausted on the date of service of September 28, 
2022. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) 
provided on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is 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 
pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and 
accessory (E0667), to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a PCD and accessory. You say that the items are medically necessary. The 
Plan denied your request. The Plan says there are in-network provider(s) within a reasonable distance from the 
enrollee's location that can provide this service or item. 
 
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 pneumatic compression device (PCD) (E0651) and accessory (E0667), 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 a walker with an enclosed frame (E0144). 
 
You asked the Plan to pre-approve a walker with an enclosed frame. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a walker with an enclosed frame (E0144) has not 
been established. Therefore, if an enclosed frame walker is provided, it will be denied as not reasonable and 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a walker with an enclosed frame have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a walker with an enclosed frame (E0144).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair basket (E1399). 
 
You asked the Plan to pre-approve a wheelchair basket. You say that you need this item. The Plan denied your 
request. The Plan says this item does not primarily serve a medical purpose. 
 
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 wheelchair basket (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for contact lenses and contact lens fitting.

You asked the Plan to provide coverage for contact lenses and contact lens fitting for the enrollee. The Plan
denied your request. The Plan says there is no indication that you have had cataract surgery. Maximus partially
overturned the Plans denial. The Plan requested a reopen and noted that Maximus did not apply the correct
contract criteria.

The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services.
However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason,
the Plan's coverage rules apply in this case. The Plan covers contact lenses after cataract surgery and does not
cover contact lens fittings. The records do not show cataract surgery took place.

Therefore, we decided that the Plan does not have to provide coverage for contact lenses and contact lens
fitting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A5500-LT and A5512-LT provided on May 
17, 2023. 
 
You asked the Plan to pay for procedure codes A5500-LT and A5512-LT. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for procedure codes A5500-LT and A5512-LT provided on May 17, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 03, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you disagree with 
the copayment applied because the only service performed was a blood draw. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care 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 an emergency room 
(ER) visit provided on June 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6021, A6199, A6212) provided on 
March 2, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that does not require separate authorization and have not been included in any other billing to treat the 
wounds described in the attached medical record documentation. The Plan denied your request. The Plan says 
the enrollee must use network providers to get her medical care and services. This provider is not a network 
provider with the Plan. 
 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 wound care supplies (A6021, A6199, A6212) 
provided on March 2, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 22 or more drug classes (G0483) provided 
on March 28, 2023. 
 
You asked the Plan to pay for the definitive drug testing of 22 or more drug classes. You say that this testing 
was medically necessary. The Plan denied your request. The Plan says that this claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0483 is definitive drug testing of 22 or more classes. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that 22 or 
more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
definitive drug testing of 22 or more drug classes have been met. Therefore, we decided that the Plan has to pay 
for the definitive drug testing of 22 or more drug classes (G0483) provided on March 28, 2023.  
 
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 pre-approve injection, anesthetic agent; stellate ganglion (64510) and 
ultrasonic guidance for needle placement (76942). 
 
You asked the Plan to pre-approve the nerve block. You say that the enrollee is in extreme pain and discomfort. 
You say that the doctor did not attach the correct diagnosis codes. You also say that the treatment will help 
you. The Plan denied your request. The Plan says this injection is covered for pain. The Plan also says that the 
records indicate that you do not meet these criteria. 
 
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 nerve block. Our reviewer says that the requested stellate ganglion nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation submitted does not support the medical necessity for the 
stellate ganglion injection with the submitted diagnoses. The reviewer found that there was no clinical 
objective documentation showing how the requested nerve block stellate ganglion injection will help with the 
enrollee's symptoms. Therefore, the reviewer found that the items/services at issue in this case are 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection, anesthetic agent; stellate ganglion (64510) and ultrasonic guidance for needle 
placement (76942).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 You asked the Plan to pre-approve the home ventilator. You say that you would like a better version of the 
Rotech BiPAP that your doctor states will work best for the health issues you are going through. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary for the enrollee because your 
needs can be met with an alternative device such as a BiPAP device with average volume-assured pressure 
support (AVAPS).  
 
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 the home ventilator. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found you do not have documented failure of 
BiPAP or finding documented to suggest the need for a home ventilator. Hence, you do not meet criteria for a 
home ventilator per data and the documentation provided. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tempur-Pedic bed. 
 
You asked the Plan to pre-approve the requested bed. You say that the pillows do not ease your pain. The Plan 
denied your request. The Plan says the bed does not meet the definition of durable medical equipment. 
 
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 Tempur-Pedic bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 28, 2021, 
to January 3, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis billed was correct, and the DRG should be paid as billed. The Plan denied your request. The Plan 
says the diagnosis of J15.6 (Pneumonia due to other Gram-negative bacteria) is not supported by the medical 
record. Although the diagnosis of pneumonitis bacterial vs viral was documented, reasonable clinical evidence 
within the health record must be present to clinically validate the diagnosis. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a diagnosis of J15.6 (Pneumonia due to other Gram-
negative bacteria). 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the diagnosis of J15.6 (Pneumonia due to other 
Gram-negative bacteria) is not supported by the medical record. Our physician reviewer found the enrollee as 
evaluated for weakness and a fall.  She was found to have had a cerebrovascular accident (CVA).  There is no 
documentation of respiratory issues or treatment.  Therefore, a diagnosis of J15.6 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 28, 2021, to January 3, 2022, at the Diagnosis Related 
Group (DRG) originally billed.