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

We decided that the Plan does not have to pay for the physician services provided to the enrollee on June 14,
2022.

You asked the Plan to pay for the physician services. You say that you have provided proof of enrollment from
CMS for this provider. The Plan denied your request. The Plan says that the Medicare Advantage Plan is
prohibited from paying claims for care provided to our Medicare Advantage Plan members by providers who
have been excluded from participation in federal programs at the time services were rendered. Maximus
overturned the Plan's decision for insufficient information in the case file. The Plan requested a reopen and
provided documentation to show that as of April 20, 2022, the provider is in an exclusion status for Medicare
claims.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a physician or practitioner who has
opted out of the program except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
information, we decided that Medicare rules for coverage of the physician services have not been met.
Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on
June 14, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on September
11, 2022.

You asked the Plan to pay for the physician services. You say that you have provided proof of enrollment from
CMS for this provider. The Plan denied your request. The Plan says that the Medicare Advantage Plan is
prohibited from paying claims for care provided to our Medicare Advantage Plan members by providers who
have been excluded from participating in federal programs at the time services were rendered. Maximus
overturned the Plan's decision for insufficient information in the case file. The Plan requested a reopen and
provided documentation to show that as of April 20, 2022, the provider is in an exclusion status for Medicare
claims.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a physician or practitioner who has
opted out of the program except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on
September 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and attachments
for the enrollee.

You asked the Plan to pre-approve a Group 3 power wheelchair and attachments. You say that this is medically
necessary. The Plan denied your request. The Plan says that the enrollee does not have a medical need for
multiple power options.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 power
wheelchair and attachments. Our Medical Director states that the enrollee has a diagnosis of amyotrophic
lateral sclerosis (ALS). It is documented that the enrollee has had a steep and rapid decline in function. A PEG
tube has been placed for nutrition. The enrollee uses a wheeled walker at all times. She can ambulate 100 feet
with the assistance of a cane or walker. The enrollee is independent with bathing, grooming, dressing and
toileting. Sensation is intact, and she has no history of skin breakdown. Clinical documentation dated March
28, 2023, indicated that the patient has weakness and is unable to propel a manual wheelchair. She is noted to
have compromised respiratory function and trunk control. She uses an ankle foot orthosis for ambulation. She
is noted to have spasticity and is unable to speak and swallow. The available clinical documentation did not
sufficiently support that the enrollee in this case met the coverage criteria for a Group 3 power wheelchair with
the requested components. Our Medical Director found that your condition does not meet criteria for a Group 3
power wheelchair (K0861) and attachments.

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 Group 3 power wheelchair and attachments have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and attachments for
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extracorporeal shock wave therapy 
services (0101T) provided from April 5, 2023, through May 8, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the extracorporeal shock wave therapy services (0101T) 
provided from April 5, 2023, through May 8, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services provided to the enrollee
on June 6, 2022.

You asked the Plan to pay for the ER services. You say that the service was medically necessary. The Plan
denied your request. The Plan says that the provider is not enrolled in Medicare. Maximus overturned the
Plan's decision for insufficient information in the case file. The Plan requested a reopen and provided
documentation to show that as of April 20, 2022, the provider is in an exclusion status for Medicare claims.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a physician or practitioner who has
opted out of the program except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided to the
enrollee on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that this will primarily be used in intelligent volume-
assured pressure support (IVAPS) mode which is specific to this device. You also say that this is medically 
necessary. The Plan denied your request. The Plan says a home mechanical ventilator set in Volume Targeted 
SIMV mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 ventilator. Our reviewer says that 
the requested ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The records provided are 
insufficient to establish that the elements of the coverage criteria are satisfied. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
Therefore, the reviewer found that the requested ventilator 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an in-home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810, 97811) 
provided on June 13, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are 
not payable as they were rendered by an ineligible provider.  
 
 
 
  
 
 
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to issue reimbursement for the acupuncture 
treatments (97810, 97811) provided on June 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 28, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not be 
held responsible for 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on July 28, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services provided to the enrollee
on May 31, 2022.

You asked the Plan to pay for the ER services. You say that you have provided proof of enrollment from CMS
for this provider. The Plan denied your request. The Plan says that this provider has been precluded from
participation in Medicare at the time services were rendered. Maximus overturned the Plan's decision for
insufficient information in the case file. The Plan requested a reopen and provided documentation to show that
as of April 20, 2022, the provider is in an exclusion status for Medicare claims.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a physician or practitioner who has
opted out of the program except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided to the
enrollee on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral radiographic image (D0230) and a panoramic 
radiographic image (D0330) provided on June 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the x-rays were needed for other dental services 
to be performed. The Plan denied your request. The Plan says your benefit for the requested items or services 
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 the Plan paid for an intraoral radiographic image (D0220) on June 23, 2023; therefore, your benefit for 
the intraoral radiographic image (D0230) was exhausted on the date of service of June 23, 2023. The record 
also shows that the Plan paid for a panoramic radiographic image (D0330) on May 19, 2021; therefore, your 
benefit for the panoramic radiographic image (D0330) was exhausted on the date of service of May 19, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral radiographic image (D0230) and a 
panoramic radiographic image (D0330) provided on June 23, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on September
9, 2022.

You asked the Plan to pay for the physician services. You say that you have provided proof of enrollment from
CMS for this provider. The Plan denied your request. The Plan says that this provider has been precluded from
participation in Medicare at the time services were rendered. Maximus overturned the Plan's decision for
insufficient information in the case file. The Plan requested a reopen and provided documentation to show that
as of April 20, 2022, the provider is in an exclusion status for Medicare claims.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a physician or practitioner who has
opted out of the program except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on
September 9, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has pre-approve Keytruda. 
 
You asked the Plan pre-approve Keytruda. You say that the enrollee has a prior history of prostate cancer 
treated with radiation; therefore, they cannot receive additional radiation treatment to the pelvic area. You say 
that the enrollee is not a candidate for cystectomy due to their poor renal function and performance status, and 
that that enrollee is not a candidate for a platinum-based chemotherapy due to poor renal function. The Plan 
denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 pre-approve Keytruda. Our reviewer found that the use 
of the requested drug is supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. The National Comprehensive Cancer Network (NCCN) guidelines for 
muscle invasive bladder cancer suggest if the enrollee is a not candidate for surgery, radiation, and platinum-
based chemotherapy then to consider Pembrolizumab (i.e., Keytruda). Keytruda has been demonstrated to be 
safe and effective in patients with renal disease and cardiovascular disease. Our physician reviewer found the 
requested drug is 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 Keytruda have been met. Therefore, we decided that the Plan has pre-approve 
Keytruda.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a 
cleaning (D1110) provided by an out-of-network provider on May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not realize that the dentist you have 
always seen would not be covered and the services should be covered. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and 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. 
 
  The record shows you received the requested 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 pay for a periodic oral evaluation (D0120), bitewings (D0274), and a cleaning (D1110) provided by an out-
of-network provider on May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2023, billed with 
codes 87481, 87491, 87563, 87653, 87798, 87641, 87500, and 87640. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 31, 2023, billed with codes 87481, 87491, 87563, 87653, 87798, 87641, 87500, and 87640.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27279). 
 
You asked the Plan to pre-approve SI joint fusion. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity for the minimally invasive percutaneous SI joint fusion is not 
established. 
 
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 SI joint fusion. 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 SI joint instability fracture or lesion. SI joint fusion for degenerative back pain is 
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 SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of implant body (D6100) for tooth #19 
and #21 provided on July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to get the dentist claim paid 
through your medical benefits. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because implants and all associated services are not covered by the Plan. 
 
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. 
 
The requested surgical removal of implant body in dispute meets the Medicare definition of dental, since it is a 
service which involved the care and treatment of teeth or structures directly supporting the teeth. The surgical 
removal of implant body does not fall under any of Medicare exceptions for coverage of non-routine dental 
care. 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 pay for 
the surgical removal of implant body (D6100) for tooth #19 and #21 provided on July 17, 2023.