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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651) and segmental 
pneumatic appliances (E0667) provided July 8, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this durable medical equipment 
was issued to you after the surgery to reduce swelling and pain afterwards. The Plan denied your request. The 
Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during 
and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 a pneumatic compression device (E0651) and segmental pneumatic appliances (E0667) provided July 
8, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit on June 27, 2023. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was seen out of necessity. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
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. We find that the enrollee was enrolled in a Preferred Provider Organization 
(PPO) contract on the date of service. Therefore, the Plans denial reason is not supported, and they did not 
give us any other evidence/rationale to support a denial. Therefore, we decided that the Plan has to pay for an 
office visit on June 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SIJI. 
 
You asked the Plan to pre-approve a SIJI. You say that the enrollee requires the requested procedure because 
they are unable to sit or stand for extended periods of time. The Plan denied your request. The Plan says the 
requested procedure does not meet the necessary requirements for approval. 
 
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 a SIJI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, there was no documentation of pain on provocative testing of the sacroiliac 
joint (on exam 10/31/2023). The review has determined that the enrollee does not meet the LCD criteria for 
coverage. 
 
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 SIJI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a SIJI.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ibsrela. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary. 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 Ibsrela.  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the injection. You say that you have been dealing with back problems for 
many years and the last time your pain was this bad you did not get relief until the third injection. 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 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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of at least 50% sustained improvement in pain relief and/or 
improvement in function measured from your baseline for at least three months from the previous ESI. There is 
no documentation provided indicating that the requested ESI will be performed using a different approach, 
level and/or medication if appropriate. Therefore, the criteria for coverage have not been met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ESI.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We have decided that the Plan does not have to provide coverage for (D4249) gum surgery to expose more
tooth crown for teeth 18 and 30, (D6750) white glass with high gold content cap for bridge for teeth 2, 4, 11,
13, 14 and 16, and (D6240) false tooth for bridge for teeth 3, 12 and 15.

You asked the Plan to provide coverage for dental services to include a dental bridge and false tooth. The Plan
denied your request.

The Plan says based on the dental x-rays provided, the coverage criteria were not met. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria. The Plan noted that to approve a bridge you must be missing only one upper front tooth or only two
lower front teeth and the two lower front teeth must be next to each other. You also cannot be missing any of
your back teeth. Based on the x-rays provided, you are missing other teeth that prevent coverage of these dental
services.

The Plan is correct in this case. 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 dental x-rays show you are missing
teeth required to be present to support these services. Therefore, we decided that the Plan does not have to
provide coverage for (D4249) gum surgery to expose more tooth crown for teeth 18 and 30, (D6750) white
glass with high gold content cap for bridge for teeth 2, 4, 11, 13, 14 and 16, and (D6240) false tooth for bridge
for teeth 3, 12 and 15.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on July 23, 2023. 
 
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 this coding is not supported. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the medical decision making is 
not of moderate complexity. As such, the billing of CPT 99284 is not supported. 
 
We looked at this coder'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 pay for emergency room services (procedure code 99284) rendered on July 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services and to pay for 
the self-administered drugs received on November 15, 2021. 
 
You asked the Plan to waive the copayment for the emergency room services and to pay for the self-
administered drugs. You say that you disagree with the amount for services received. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. The Plan also says that self-administered drugs 
are not covered. 
 
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 $90 
copayment for Emergency care. The rules also 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. 
 
You have been asked to pay a $90 copayment for the emergency room services. 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. You have also been asked to pay for the self-administered drugs. The self-administered drugs 
received are not covered. Therefore, we decided that the Plan does not have to waive the copayment for the 
emergency room services and to pay for the self-administered drugs received on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 8, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 8, 2023, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography (93306) provided on 
February 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic service. You say that you are appealing the denial of payment as 
your doctor was on-call at the hospital to see any cardiac patients on this date. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the transthoracic echocardiography (93306) 
provided on February 19, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and the complexity of their medical, rehabilitation, 
and nursing needs does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary 
approach to rehabilitative care. The enrollee does not need physician supervision 3 times a week or intensive 
therapies in an IRF. The enrollees rehabilitation needs can safely be provided in an alternate setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99211 billed for date of service January 14, 
2022.   
You asked the Plan to pay for procedure code 99211. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99211 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99211 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99211 billed for date of service January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided June 2, 
2023.  
You asked the Plan to pay for the ultraviolet light therapy system. You say that please review and reprocess the 
claim. The Plan denied your request. The Plan says the records do not show that the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record does not show a diagnosis of psoriasis. There is also no 
documentation that a face-to-face encounter took place between this enrollee and the ordering provider. Based 
on this information, we decided that Medicare rules for coverage of the ultraviolet light therapy system have 
not been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy system 
(E0691) provided June 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0012M for date of service May 17, 2023. 
 
You asked the Plan to pay for procedure code 0012M. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0012M is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue was billed with 
code 0012M. This code is specifically not covered. Based on this information, we decided that Medicare rules 
for coverage of procedure code 0012M have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 0012M for date of service May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82728, 83540, and 85025 for date of service 
April 28, 2023. 
 
You asked the Plan to pay for procedure code 82728, 83540, and 85025. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 82728, 83540, and 85025 are not supported in the medical record. Specifically, the 
medical records submitted indicate that the services were performed on May 1, 2023. The claim form 
submitted indicates April 28, 2023. The date discrepancy means the validity and accuracy of the claim cannot 
be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 82728, 83540, and 85025 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 82728, 83540, and 85025 for date of service April 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the sleep study rendered on May 26, 2023, 
and May 27, 2023. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
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 in-network Medicare-covered non-radiological diagnostic services.  
 
Review of the file shows that you received a sleep study from May 26, 2023, to May 27, 2023. You have been 
asked to pay a 20% coinsurance for these services. This item/service falls within the in-network Medicare-
covered non-radiological diagnostic 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 coinsurance 
for the sleep study rendered on May 26, 2023, and May 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service April 20, 
2023. 
 You asked the Plan to pay for procedure code 81345. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 81345 billed for date of service April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve a percutaneous vertebral augmentation. You say that you have issues with 
your hip after falling and need surgery. The Plan denied your request. The Plan says the request 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 a percutaneous vertebral augmentation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no trial of fracture bracing and more conservative measures are 
needed 
 
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 percutaneous vertebral augmentation. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation.