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

We decided that the Plan does not have to pre-approve twenty (20) additional fractions of intensity-modulated
radiation therapy (IMRT) and stereoscopic guidance for the enrollee.

You asked the Plan to pre-approve twenty (20) additional fractions of Intensity modulated Radiation Therapy
(IMRT) and stereoscopic guidance. You say that regular Medicare would cover the enrollee's treatment. The
Plan denied your request. The Plan says that these 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 twenty (20) additional fractions of
IMRT and stereoscopic guidance. Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Delivering 100 Gy to a skin cancer is not supported by any
guidelines nor published evidence and would be a major deviation from the standard of care, and not consistent
with what is described in the consult note. Our physician reviewer found that the enrollee's condition does not
meet criteria for coverage of these 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 twenty (20) additional fractions of IMRT and stereoscopic guidance have not
been met. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional fractions of
intensity-modulated radiation therapy (IMRT) and stereoscopic guidance for the enrollee.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the services may be provided at a lower level of care.  
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that 
this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status.  The enrollee can receive further services at a lower 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 for the routine vision eyewear.

You asked the Plan to pay for these services. You say that you don't understand why the plan didn't pay the full
$300 benefit. The Plan denied your request. The Plan says the claim was processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $300 every calendar year for supplemental eye wear.

We looked at the file and the Plan's rules. The file shows that the total amount for the charges was $740. The
Plan applied the full $300 supplemental benefit for routine eye wear. This left you with a balance of $350.
Further reimbursement is not covered by your supplemental benefit or Medicare. Therefore, we decided that
the Plan does not have to pay for the routine vision eyewear
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Special Supplemental Benefits for the
Chronically Ill (SSBCI).

You asked the Plan to provide coverage for these supplemental benefits. The Plan denied your request. The
Plan says your provider did not submit medical records to show you meet the required criteria. Maximus
overturned the Plans denial for a lack of information in the case file. The Plan requested a reopen and provided
the required information.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
benefit information. The Plan contract is clear that specific documentation must be presented for you to receive
coverage for SSBCI benefits. The Plan requested medical records from your physician to support your need for
these benefits. Those records were not submitted by your physician. Therefore, we decided that the Plan does
not have to provide coverage for Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 22, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 22, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 enrollee has mixed hyperlipidemia 
and atherosclerotic heart disease of the native coronary artery. He has not tried and failed the Plan's required 
drug, zoledronic acid. The records do not show that the required drug would be contraindicated or less 
effective; therefore, Leqvio is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Leqvio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says insufficient information was provided to support the request. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Prolia have been met. No medical 
records were provided for review.  Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc NP at L3-4, L4-5, and L5-S1. 
 
You asked the Plan to pre-approve VIA Disc NP. 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 VIA Disc NP. 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 compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested VIA Disc NP at L3-4, L4-5, and L5-
S1 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 VIA Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA Disc NP at L3-4, L4-5, and L5-S1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), cervical spine x-ray (72050), and 
shoulder x-rays (73030 x 2) provided on May 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that you were referred for these services by your 
primary care physician who is in-network. You also say that you did not know that you needed authorization in 
addition to a referral. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The referring provider is not a network 
provider either. 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 office visit (99214), cervical spine x-ray (72050), and shoulder x-rays (73030 x 2) provided on May 8, 
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 you need the IRF admission to help with adjusting to 
prosthesis. The Plan denied your request. The Plan says you do not meet the criteria for the IRF admission.  
 
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 you are medically stable and the complexity of your medical, rehab, and nursing 
needs does not require acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative 
care. The IRF admission is not necessary and is not reasonable. Your rehab needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing facility.  
 
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 provide coverage for special supplemental benefits for the
chronically ill (SSBCI).

You asked the Plan to provide coverage for these benefits. The Plan denied your request. The Plan says based
on the records provided, you do not meet these criteria. Maximus overturned the Plans denial because the
medical records were not in the case file. The Plan requested a reopen and provided the required records.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
benefit information. Your contract with the Plan clearly says that you must meet specific coverage criteria for
SSBCI benefits. Based on the medical records provided, you did not meet the criteria required at the time of the
appeal. Therefore, we decided that the Plan does not have to provide coverage for special supplemental
benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 provided on June 8, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services 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. 
 
In this case, the CPT Code Manual definition of code 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this code is a not otherwise 
specified code, and the documentation does not contain a complete description of the not otherwise specified 
code. Based on this information, we decided that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87798 provided on 
June 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty surgery to be rendered by an 
out-of-network provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary. This 
service can be obtained by contracted providers within the Plan. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 this service. Our reviewer says that you 
do not meet criteria for coverage of the requested service. Our physician reviewer found that you were being 
treated for primary osteoarthritis of the bilateral knees. You presented with right knee persistent pain that has 
been worsening. You have a knee replacement planned. The exam revealed tenderness to palpation of the 
medial joint line. The x-rays provided are noted to show intact surgical hardware and end-stage medial 
compartment osteoarthritis. However, detailed documentation is not evident regarding any significant findings 
on exam or by diagnostic imaging studies that require the requested surgery to be performed by one specific 
provider over another. The rationale for medical necessity of an out-of-network provider has not been 
established. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, you do not meet the criteria for continuity of care 
in this case for the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total knee arthroplasty surgery to be rendered by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service June 6, 2023.  
 
You asked the Plan to pay for procedure code 93355. You say that 93355 should be paid as billed because it 
was billed on the same claim as all other codes for this date of service and it is supported in the medical record. 
The Plan denied your request. The Plan says payment for code 93355 is bundled into payment for code 00560. 
 
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 93355 
is a column two code to column one code 00560 with a modifier indicator of 0. The column two 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 93355 billed for date of service June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision eye wear.

You asked the Plan to pay for these services. You say that you don't understand why the plan didn't pay the full
$300 benefit. The Plan denied your request. The Plan says the claim was processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers a $300 maximum plan allowance for supplemental eye wear every calendar year.

We looked at the file and the Plan's rules. The file shows that the total charges for these services was $565. The
Plan applied the full $300 supplemental benefit towards these services. Further payment is not covered by your
supplemental benefit or Medicare. Therefore, we decided that the Plan does not have to pay for the routine
vision eye wear rendered on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion office visit and treatment with an 
OON provider.  
 
You asked the Plan to pre-approve a second opinion office visit and treatment. You say that you feel you need 
to see a specialized provider due to being high risk. The Plan denied your request. The Plan says the requested 
provider is OON; the service can be provided by an in-network provider. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 second opinion office visit and treatment. Our reviewer says the service is 
not medically necessary. Our physician reviewer found that there is nothing unique about your condition that 
would make it medically necessary to request an out-of-network provider. The Plan has shown that they have 
in-network providers who meet the Standards of Care required for treatment of your condition. 
 
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 second opinion office visit and treatment have not been met.  
 
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 a second opinion office visit and treatment. Therefore, 
we decided that the Plan does not have to pre-approve a second opinion office visit and treatment with an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service May 30, 
2023. 
 
You asked the Plan to pay for procedure code 99024. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99024 is considered bundled and not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service May 30, 2023.