Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower extremity, below knee (BK), total 
contact. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this exceeds the enrollee's needs. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the plan is technically correct in their denial. No established code for the requested feature 
currently exists. The feature is novel. The "not otherwise specified" code L7499 would be more appropriate for 
this request. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve addition to lower extremity, below knee (BK), total contact.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on April 20, 2022, by 
a non-Medicare enrolled provider. 
 
You asked the Plan to pay for the emergency room services. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says the treating provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
on April 20, 2022, by a non-Medicare enrolled provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service February 10, 
2023.  
 
You asked the Plan to pay for procedure code 69990. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 69990 is bundled into payment for code 63030. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 69990 
is a column II code to column I code 63030 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 69990 billed for date of service February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group 2 standard power wheelchair (K0823) purchased 
on March 7, 2023. 
 
You asked the Plan to pay for the group 2 standard power wheelchair. You say that you had no choice but to 
order the Vibe 4-wheel mobility scooter. You also say that the provider you purchased this from was cheaper 
than the same item from other companies. The Plan denied your request. The Plan says the provider you 
purchased this item from is not a valid durable medical equipment provider. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for Medicare-covered items 
or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. 
 
We looked at the file and Medicare rules. Specifically, the providers you purchased these items from are not 
enrolled in Medicare, and therefore, are not eligible for payment. Based on this information, we decided that 
Medicare rules for coverage of the group 2 standard power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pay for the group 2 standard power wheelchair (K0823) purchased on 
March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network back brace 
 
You asked the Plan to waive the coinsurance for an in-network back brace. You say that you are very upset by 
this charge, no one told you it would be happening.  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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
The allowed amount of this drug is $705.60, resulting in a coinsurance amount of $141.12 ($705.60 x 20% = 
$141.12). You have been asked to pay a $141.12 coinsurance for an in-network back brace. This item/service falls within 
the durable medical equipment (DME) 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for an in-network back brace
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show a failure to respond to conservative management. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease (DJD) or foraminal stenosis. The cause of the back pain is not clear. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 23430 rendered on December 13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the service is not supported without the required documentation. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The case narrative states that medical records were submitted for this appeal. 
These medical records were not provided for review for MAXIMUS. Therefore, we decided that the Plan has to 
pay for procedure code 23430 rendered on December 13, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) and trigger point injections 
(20553) provided on February 11, 2023. 
 
You asked the Plan to pay for the outpatient office visit and trigger point injections. You say that you would 
like this claim to be reconsidered for payment. The Plan denied your request. The Plan says the treating 
provider is a Medicare opt out provider and is not eligible to participate in Medicare. 
 
 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99213) and trigger point injections (20553) provided on February 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 10, 2023, 
by a provider who is not enrolled in Medicare. 
 
  You asked the Plan to pay for the emergency room services. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says due to the fact that these facilities are not hospitals, 
and are not affiliated with a hospital, they are actually unable to obtain Medicare approval/certification. The 
Plan also says that Medicare guidance allowing for payment on emergent hospital claims for non-Medicare 
certified hospitals does not apply to non-Medicare freestanding emergency facilities. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. Medicare rules also say that Medicare covers services in an 
emergency department only if the emergency clinic is affiliated with the hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The documentation provided also states that the facility in question is not an actual hospital and has 
no affiliation with a hospital. Therefore, we decided that the Plan does not have to pay for the emergency room 
services provided on February 10, 2023, by a provider who is not enrolled in Medicare.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a K3 microprocessor foot. 
 
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 K3 microprocessor foot is 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 enrollee's K3 ambulation status is 
lengthy, detailed, and corroborated by both the treating physician and physical therapist in the submitted 
records. The requested K3 microprocessor foot is within the standard of care and is medically necessary for this 
enrollee with quadrilateral amputations and activity potential that would benefit from the prosthetic feet. 
 
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 K3 microprocessor foot.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on March 3, 2023, by 
a non-Medicare enrolled provider. 
 
You asked the Plan to pay for the emergency room services. The Plan denied your request. The Plan says this 
claim processed correctly as there is no evidence of enrollment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
on March 3, 2023, by a non-Medicare enrolled provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxybutynin chloride. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
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 oxybutynin chloride.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from January 3, 2023, to January 6, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you should not 
have to pay this copayment, because you had to be transferred to a different inpatient facility. This was not 
your choice. 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 $310 
copayment per day, for days 1-5 for inpatient hospital services.  
 
You were in the hospital for 3 days, resulting in a $930 total copayment ($310 x 3 = $930). 
 You have been asked to pay a $930 copayment for an in-network acute inpatient stay. This item/service falls 
within the inpatient hospital 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 
an in-network acute inpatient stay provided from January 3, 2023, to January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist visit provided on 
February 28, 2023, and March 10, 2023. 
 
You asked the Plan to waive the copayment for an in-network specialist visit. You say that you should not have 
these copayments, you cannot afford them. 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 $40 
copayment for physician/practitioner services, including doctor's office visits.  
 
You had two visits, resulting in an $80 total copayment ($40 x 2 = $80). You have been asked to pay an $80 total copayment for an in-network specialist visit. This item/service falls 
within the physician/practitioner services, including doctor's office visits 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 in-network specialist visit provided on February 28, 2023, and 
March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dayspring non-pneumatic compression device and 
half leg garment described by codes K1024 and K1033. 
 
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 the services 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the current peer-reviewed medical 
literature does not support that the requested Dayspring non-pneumatic compression device has been shown in 
controlled studies in a Medicare-approved journal to result in long-term health benefits for the treatment of 
lymphedema. The services are not reasonable or medically necessary 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dayspring non-pneumatic compression device and half leg garment described by codes 
K1024 and K1033.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat and a bath/shower chair. 
 
You asked the Plan to pre-approve a raised toilet seat and bath/shower chair. You say that the enrollee has 
severe arthritis and other physical limitations to perform activities of daily living. The Plan denied your 
request. The Plan says the requested services are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats and bath/shower 
chairs are not covered because they are not primarily medical in nature.  
 
While a raised toilet seat and bath/shower chair may be appropriate in this case, neither the Plan nor Medicare 
offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a raised toilet 
seat and a bath/shower chair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on March 10, 2022, 
by a provider who is not enrolled in Medicare. 
 
  You asked the Plan to pay for the emergency room services. The Plan denied your request. The Plan says 
because these facilities are not hospitals, and are not affiliated with a hospital, they are actually unable to obtain 
Medicare approval/certification. The Plan also says that Medicare guidance allowing for payment on emergent 
hospital claims for non-Medicare certified hospitals does not apply to non-Medicare freestanding emergency 
facilities. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. Medicare rules also say that Medicare covers services in an 
emergency department only if the emergency clinic is affiliated with the hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The documentation provided also states that the facility in question is not an actual hospital and has 
no affiliation with a hospital. Therefore, we decided that the Plan does not have to pay for the emergency room 
services provided on March 10, 2022, by a provider who is not enrolled in Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional crown-porcelain/ceramic. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve an additional crown-porcelain/ceramic.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drugs, two or more 
administrations, different medications (D9612) provided on September 23, 2022. 
 
You asked the Plan to pay for the deep sedation/general anesthesia - first 15 minutes (D9222), each subsequent 
15 minute increment (D9223) and therapeutic parenteral drugs, two or more administrations (D9612). You say 
that the Plan paid for anesthesia for a past extraction. The Plan denied your request. The Plan says D9612 is not 
covered under your dental benefits. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the therapeutic parenteral drugs, two or 
more administrations are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the  therapeutic parenteral drugs, two or more administrations, different medications 
(D9612) provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for cone beam CT image (D0380), resin-based composite 
(D2394) and endodontic therapy, molar tooth (D3330) provided on February 6, 2023, to February 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing amount 
when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 pay more for cone beam CT image (D0380), resin-based 
composite (D2394) and endodontic therapy, molar tooth (D3330) provided on February 6, 2023, to February 
14, 2023.