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

We decided that the Plan does not have to pay for the telephone evaluation (99442) provided to the enrollee on June 14, 2022.
You asked the Plan to pay for the telephone evaluation. You say that you disagree with the denial. The Plan denied your request. The Plan says that they have already paid for this service under a different claim.
Maximus overturned the Plan's denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We looked at the file and Medicare rules. The file indicates the Plan has already paid for one evaluation and management service (99490) on this date to this provider. Based on this information, we decided that Medicare rules for coverage of the telephone evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation (99442) provided to the enrollee on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure device (CPAP) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve CPAP. You say that there are no other provider that carries the air sense 10 
CPAP. The Plan denied your request. The Plan says this is available 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 
continuous positive airway pressure device (CPAP) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye examination and retinal 
imaging provided on January 18, 2023. 
 
You asked the Plan to waive the copayment for the medical eye examination and the retinal imaging. You say 
that you were seen for a diabetic retinopathy screening, and you were under the impression there would be a $0 
copayment. 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 per visit for Medicare-covered exams to diagnose and treat diseases of the eye.  
 
 You have been asked to pay a $40 copayment for the medical eye examination and the retinal imaging. These 
services fall within vison care benefit category. The medical record shows you received a medical eye exam in 
addition to the diabetic retinopathy screening. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the medical 
eye examination and retinal imaging provided on January 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of a SPRINT peripheral 
nerve stimulator (PNS). 
 
You asked the Plan to pre-approve a percutaneous implantation of a SPRINT peripheral nerve stimulator 
(PNS). You say that this service is medically necessary The Plan denied your request. The Plan says this 
service is considered experimental. 
 
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 implantation of a 
SPRINT peripheral nerve stimulator (PNS). Our reviewer says that the requested service is not considered 
medically reasonable and necessary in this case. Our physician reviewer found this service is considered 
experimental.  
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 implantation of a SPRINT peripheral nerve stimulator (PNS) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous 
implantation of a SPRINT peripheral nerve stimulator (PNS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires another 4 to 6 
weeks of transitioning from their acute illness as they continue to recover to their baseline of function. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can 
safely receive the care they need in the current hospital setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care panel billed for date of service January 25, 
2022. You asked the Plan to pay for the billed services. You say that the test detects pathogens that lead to infections. 
The Plan denied your request. The Plan says the service is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are no medical records from the treating provider 
to show that the testing was ordered for a specific medical problem. The panel was also not billed with a single 
code as required. Based on this information, we decided that the Medicare rules for overage have not been met. 
Therefore, we decided that the Plan does not have to pay for the wound care panel billed for date of service 
January 25, 2022.
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 enrollee needs rehab services for physical 
therapy. The Plan denied your request. The Plan says ongoing skilled care can be provided in an alternative 
setting. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composites (D2394, D2332) provided on June 22, 2022.
You asked the Plan to pay more for the dental services. You say that you are due additional reimbursement for these services. 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. Maximus overturned the Plan's denial because the relevant EOC was not submitted. The Plan requested a reopening and included the correct EOC.
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 the resin-based composites (D2394, D2332) provided on June 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic angiography (CTA), chest 
(noncoronary), with contrast material(s), including non-contrast images, if performed, and image 
postprocessing (71275). 
 
You asked the Plan to pre-approve computed tomographic angiography (CTA). You say that the scan is 
important to receive, the enrollee's condition, more chest tightness and discomfort from an aortic aneurysm. 
The Plan denied your request. The Plan says this testing only supported every six months for an aneurysm (a 
bulging weak spot in the wall of your blood vessel) located in the part of the aorta (largest blood vessel in the 
body) that exits the heart and curves in the upper chest (ascending aorta) that measures 4.0 centimeters or 
greater. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve computed tomographic angiography (CTA). Our reviewer says that the service is not medically necessary. Our physician reviewer found the review 
has determined that given the documentation provided for review, the requested CTA scan is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computed tomographic angiography (CTA), chest (noncoronary), with contrast 
material(s), including non-contrast images, if performed, and image postprocessing (71275) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computed tomographic angiography (CTA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upgrade of the patient's current Implantable 
Cardioverter Defibrillator (ICD) to a Cardiac Resynchronization Therapy with Defibrillator (CRT-D). 
 
You asked the Plan to pre-approve a CRT-D. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service 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 CRT-D. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found BiVentricular pacing is not indicated in patients with a normal Left Ventricular Ejection Fraction 
(LVEF) and there are no randomized clinical trials to show any benefit from preventive dys-synchrony. 
 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 CRT-D have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an upgrade of the patient's current Implantable Cardioverter Defibrillator (ICD) to a Cardiac 
Resynchronization Therapy with Defibrillator (CRT-D).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic-porcelain/ceramic for teeth #10, #11, #12 
(D6245). 
 
 
You asked the Plan to pre-approve pontic. You say that this should be covered. The Plan denied your request. 
The Plan says this service is covered for a maximum of 2 teeth, since this bridge is for more than 2 teeth it is 
not covered. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
pontic-porcelain/ceramic for teeth #10, #11, #12 (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 16, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting the submitted documentation be 
reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
November 16, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 enrollee appears to be somewhat unstable and requires additional short term acute 
care services that can be safely administered at the current facility until more stable for transfer. 
 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: 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 enrollee is ready for discharge and 
their medical needs are not able to be met in a lower level of care. The Plan denied your request. The Plan says 
the enrollee's medical needs are being met in the current setting. 
 
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 enrollee appears to still be somewhat unstable and requires additional short-term 
acute care services that can safely be provided at the current facility until more stable for transfer. The enrollee 
does not require services at the LTACH that are not already available at the current facility. Completion of 
treatment at the current facility is recommended. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve the home health skilled nursing services. You say that you are weak and get 
tired very easily. You also say that you cannot be left alone without any assistance because you have fallen a 
couple of times. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 health skilled nursing 
services. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found the documentation doesn't support you require additional skilled nursing services to provide 
treatment that is medically necessary. You do not require additional skilled nursing services to effectively 
provide treatment, care, and/or service in order to improve your condition, perform maintenance program to 
maintain your condition or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services 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 home health skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontist visit (D9999). 
 
You asked the Plan to pre-approve the endodontist visit (D9999). You say that this is money that you don't 
have and it is a procedure you are trying to get done early so it won't be expensive once it gets infected. You 
also say that you have to get it done, it is not a beauty thing, it is related to your health. The Plan denied your 
request. The Plan says dental services from an out-of-network provider 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. 
 
 
 You are requesting 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 pre-approve an 
endodontist visit (D9999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided to the enrollee on May 12, 2022.
You asked the Plan to pay for the x-ray services. You say that you do not have access to hospital records. The Plan denied your request. The Plan says that it is inappropriate to bill an outpatient place of service.
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital inpatients, the inpatient hospital POS code would be reported regardless of where the face-to-face service takes place. POS code 21 is used to describe an inpatient hospital.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Specifically, this claim was not billed with the inpatient hospital POS code. The records support that the enrollee was an inpatient in the hospital on the date of service the x-ray was provided. Therefore, we decided that the Plan does not have to pay for the x-ray services provided to the enrollee on May 12, 2022.