Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (33340) and inpatient admission provided on July 20, 2022, to July 21, 
2022, by an out-of-network (OON) provider.  
   
You asked the Plan to pay for percutaneous transcatheter closure of the left atrial appendage with endocardial 
implant and inpatient admission. You say that the hospitalization and services provided were necessary. The 
Plan denied your request. The Plan says the provider was out-of-network, and no prior authorization was 
submitted for the services. 
 
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 percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (33340) and inpatient admission provided on July 20, 2022, to July 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 5, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you disagree with 
the 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $225 copayment for ambulance services.  
 
The enrollee has been asked to pay a $225 copayment for the ambulance transportation provided on July 5, 
2023. This item/service falls within the ambulance services benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the ambulance transportation provided on July 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on 
December 15, 2022. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were able to drive 
the enrollee to the hospital instead of riding in the ambulance. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning, bitewing x-rays, and filling for tooth #15 (D0120, 
D1110, D0274) provided on September 7, 2023, to September 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 on date of service September 7, 2023. 
Therefore, we decided that the Plan does not have to pay for a cleaning, bitewing x-rays, and filling for tooth 
#15 (D0120, D1110, D0274) provided on September 7, 2023, to September 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity and of the leg joint before and after contrast. 
 
You asked the Plan to pre-approve the MRI. You say that you are having extreme pain due to a torn tendon in 
the hamstring and the pain is not going away. The Plan denied your request. The Plan says there is no 
documentation showing why the services are needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found there is no trial and failure of physical therapy 
for leg pain. More conservative measures are needed before the MRI could be approved. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity and of the leg joint before and after 
contrast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve branch block (64454). 
 
You asked the Plan to pre-approve a genicular nerve branch block. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 a genicular nerve branch block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested genicular nerve branch 
block bilaterally 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 a genicular nerve branch block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular nerve branch block (64454).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain stem. 
 
You asked the Plan to pre-approve the MRI. You say that the imaging is medically necessary. 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 MRIs 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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation of focal neurologic 
deficits or any other criteria that would meet coverage for an MRI of the brainstem. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the brain stem.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance crowns for teeth #8 and #9 (D2740) provided 
on July 2, 2021. 
 
You asked the Plan to waive the coinsurance the dental services. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 have been asked to pay a 70% coinsurance for crowns for teeth #8 and #9. This item/service falls within 
the Dental 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 crowns for teeth #8 and 
#9 (D2740) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 99233 and 99232 provided from November
1, 2021, to November 7, 2021.

You asked the Plan to pay for procedure codes 99233 and 99232. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a
previously paid claim and was correctly denied. Maximus overturned the Plan's denial for a lack of
information. The Plan requested a reopening and provided the original paid claim. The rules say that claims or
claim lines that have been determined to be exact duplicates of another claim or claim line are denied. The file
includes evidence that the items/services at issue were reimbursed by the Plan on June 1, 2022. Comparison of
the two claims shows these are exact duplicates. There is no evidence presented to support that the billed
items/services were provided twice on the same date. Based on this information, we decided that the Medicare
rules for procedure codes 99233 and 99232 have not been met. Therefore, we decided that the Plan does not
have to pay for procedure codes 99233 and 99232 provided from November 1, 2021, to November 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve the pontic - porcelain/ceramic. You say that you need the dental bridge so 
you can eat properly. The Plan denied your request. The Plan says a dental bridge is not a covered benefit. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pontic - 
porcelain/ceramic (D6245).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration provided on August 29, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chemotherapy administration. You say that the services provided were 
medically necessary for the enrollee. The Plan denied your request. The Plan says the services provided were 
not emergent and urgent, nor approved in advance.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 chemotherapy administration provided on 
August 29, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on February 24, 2023. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are appealing based on medical 
necessity. 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 skilled nursing facility 
care provided on February 24, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 14, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on August 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart for 
calcium scoring. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has a chronic cardiovascular risk 
factor. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that enrollees must meet the criteria listed in the LCD in 
the Medicare rule 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 the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the patient has no chest pain and does not 
fulfill criteria for the requested services. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart for calcium scoring.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 07, 2023, to August 30, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that the services were medically necessary. 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 physical therapy 
provided on August 07, 2023, to August 30, 2023.
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 continues to demonstrate a decline in all 
basic functional mobility. You say that the enrollee is an excellent candidate for transfer to an acute inpatient 
rehabilitation facility once they are medically stable to maximize the return of function, cognition, and 
communication. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 20, 2023.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.

The Plan noted that Review of the technical assessment as found on the MolDX program website
(https://app.dexzcodes.com/app#!catalogDetailPage) indicates that the technical assessment for SelectMDx
was not effective until February 17, 2023.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid as billed as it was not eligible for payment on
the date of service. Based on this information, we decided that Medicare rules for coverage of this testing have
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the
enrollee on January 20, 2023.
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 requires an interdisciplinary approach to 
their care that couldn't be provided at a lower rehabilitation setting due to medical complexity. The Plan denied 
your request. The Plan says the request for IRF services does not meet the requirements for approval.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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.