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

 
We decided that the Plan does not have to pre-approve application of bio-engineered skin substitute to lower 
extremity chronic non-healing wound. 
 
You asked the Plan to pre-approve application of bio-engineered skin substitute to lower extremity chronic 
non-healing wound. You say that the wound has limited your ability to function daily. You feel that by 
receiving the graft procedure it would significantly increase your ability to function in daily activities. The Plan 
denied your request. The Plan says your wound has been present since March 2023, more than 12 weeks. 
Therefore, the use of skin substitutes is not covered. 
 
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 application of bio-engineered skin 
substitute to lower extremity chronic non-healing wound. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coverage 
for a skin substitute. Given that you have a wound vacuum-assisted closure (vac) and has had demonstrated 
improvement of her wound in the last month, use of the skin substitute is not 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 application of bio-engineered skin substitute to lower extremity chronic non-
healing wound have not been met. Therefore, we decided that the Plan does not have to pre-approve application 
of bio-engineered skin substitute to lower extremity chronic non-healing wound.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of single external papilla or tag (46220) and an 
office visit (99203) provided on August 8, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for excision of single external papilla or tag and an office visit with an out-of-
network provider. You say that you want the Plan to pay for the services. The Plan denied your request. The 
Plan says the provider is out-of-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 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 excision of single external papilla or tag (46220) 
and an office visit (99203) provided on August 8, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 306 Freestyle Lite test strips. 
 
You asked the Plan to pre-approve 306 Freestyle Lite test strips. You say that the items should be covered. The 
Plan denied your request. The Plan says the requested amount exceeds the allowed amount for this item. 
 The Plan must follow Medicare rules. Medicare rules say that, for a beneficiary who is currently being treated 
with insulin administrations, more than 300 test strips and more than 300 lancets every 3 months are covered if 
criteria (a)(c) in the Medicare Rules section are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 306 Freestyle Lite test strips. have not been met. Specifically, there is no indication in the records 
submitted that the amount of test strips requested are needed or medically necessary. Therefore, we decided 
that the Plan does not have to pre-approve 306 Freestyle Lite test strips.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 30, 
2023. 
 
You asked the Plan to pay for the nursing facility services. You say that our physician provided medically 
necessary services in good faith and is entitled to reimbursement. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 30, 
2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for the specialist office visits, and
drug injections provided on July 21, 2022, and October 5, 2022.

You asked the Plan to waive or reduce this cost share. The Plan denied your request. The Plan says this cost
sharing was charged correctly. Maximus partially overturned the Plan denial stating codes J1100, J2469, J9171
are considered packaged codes and are not separately payable. The Plan requested a reopen and stated that
Maximus did not apply the correct contract criteria or billing criteria.

The Plan is correct in this case. 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 for a cost share for each specialist office visit and each Medicare Part B drug.

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 or reduce the cost share for the specialist office visits, and drug
injections provided on July 21, 2022, and October 5, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s) (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), each additional facet 
joint (64636). 
 
You asked the Plan to pre-approve facet denervation. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the lumbar radiofrequency ablation procedure 
requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve facet denervation. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a past medical history of chronic neck pain and lower back pain. On 
July 31, 2019, a magnetic resonance imaging study of the lumbar spine, showed multi-level disc bulging with 
bilateral neural foraminal narrowing. On April 13, 2023, the enrollee underwent right sided radiofrequency 
ablation, which provided 50% improvement in the back pain. The enrollee then had left sided lumbar 
radiofrequency ablation performed June of 2023, which failed to provide any significant relief. The request 
exceeds the utilization limit of 2 sessions in a rolling 12-month period. Therefore, the request is deemed not 
medically reasonable and 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 facet denervation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s) (64635) and 
destruction by neurolytic agent, paravertebral facet joint nerve(s), each additional facet joint (64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, anterior tooth (excluding final 
restoration) (D3310), and cone beam CT capture and interpretation with limited field of view  less than one 
whole jaw  (D0364) provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you say that you initially contacted your plan 
dental provider and was directed to a practice who stated that they were not in your registry. Due to your 
unbearable pain and the immediate need for a root canal to your crown you went to your family dentist who 
arranged the services. 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 the endodontic therapy, anterior tooth (excluding final restoration) (D3310), and cone beam CT 
capture and interpretation with limited field of view  less than one whole jaw  (D0364) provided on January 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for incisional biopsy of oral tissue-soft (D7286) provided 
on April 3, 2023. 
 
You asked the Plan to reimburse for incisional biopsy of oral tissue-soft (D7286). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this service is not a covered 
benefit under your 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. 
 
 
  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 reimburse for 
incisional biopsy of oral tissue-soft (D7286) provided on April 3, 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 you need IRF services because you cannot move 
without assistance. The Plan denied your request. The Plan says you do not meet the criteria for an 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 stable and do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. Your rehabilitation needs can be safely provided in an 
alternate and lower-intensity setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build-up (D2950) and porcelain crown (D2750). 
 
You asked the Plan to pre-approve core build-up and porcelain crown. You say that this should be covered. The 
Plan denied your request. The Plan says these are not covered service. 
 
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 core 
build-up (D2950) and porcelain crown (D2750).
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 physical therapy to address their 
decreased activity tolerance, to increase strength, improve balance, increase mobility, transfer deficits , 
neuromuscular re-education, and atrophy. 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 enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment simulation using 3D image volume 
(D0393), the guided tissue regeneration (D4266), the bone replacement graft (D7950), and the therapeutic 
parenteral drugs (D9612) for tooth #7 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the treatment simulation using 3D image volume, the guided tissue regeneration, the bone replacement 
graft, and the therapeutic parenteral drugs 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. 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 the 
treatment simulation using 3D image volume (D0393), the guided tissue regeneration (D4266), the bone 
replacement graft (D7950), and the therapeutic parenteral drugs (D9612) for tooth #7 and #10.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on June 16, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on June 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care provided from June 2, 2023, to June 3, 2023. 
 You asked the Plan to pay for the SNF care. You say that there was no skilled event, or change in the enrollee's 
condition, at the time of transfer and no need for a notice of denial of medical coverage. The Plan denied your 
request. The Plan says the enrollee no longer required daily skilled services at a SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care. Our reviewer says that the 
requested SNF care was not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the SNF care provided from June 2, 2023, to June 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy treatment provided on May 
24, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatment. You say that you have never had to 
pay out-of-pocket before. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy treatment. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. You have been asked to pay $49.58, which is 20% of the allowed amount for 
chemotherapy treatment ($247.92 allowed x 20% = $49.58). Therefore, we decided that the Plan does not have 
to waive the coinsurance for chemotherapy treatment provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on August 9, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you believe this should be covered and paid. 
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 August 9, 2023. Therefore, we decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on 
August 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography angiography 
(CTA) scan provided on August 10, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography angiography (CTA) scan. You say that 
you strongly believe the hospital facility should be responsible for the copayments. 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 $270 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $270 copayment for a computed tomography angiography (CTA) scan. This 
item/service falls within the outpatient diagnostic tests 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 a computed tomography angiography (CTA) scan provided on August 10, 2023.