Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833). 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were 
medically necessary for the enrollees condition. The Plan denied your request. The Plan says there is no 
evidence provided that the prescribing physician ever saw the member. 
 
The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination 
of the beneficiary and objective description of joint laxity. 
 
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 knee orthosis and suspension sleeve. Our 
reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there 
is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective 
documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the 
base item is not covered. 
 
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 knee orthosis and suspension sleeve have not been met. Therefore, we 
decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that it has not been demonstrated that the patient requires skilled nursing 
services or skilled rehabilitation services. 
 
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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for topical application of aminolevulinic acid 
Hydrogen Chloride 20% (HCl) (J7308) provided on November 11, 2020, and topical application of 
aminolevulinic acid Hydrogen Chloride 10% (J7345) provided on December 10, 2020. 
 
You asked the Plan to waive the coinsurance for aminolaevulinic acid HCl. You say that you were not told you 
would have to pay for the services. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for aminolaevulinic acid HCl. The services at issue fall 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for topical application of aminolevulinic acid Hydrogen Chloride 20% (HCl) (J7308) provided on November 
11, 2020, and topical application of aminolevulinic acid Hydrogen Chloride 10% (J7345) provided on 
December 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Current Procedural Terminology (CPT) code 30903 provided 
on July 2, 2020. 
 
You asked the Plan to pay for CPT code 30903. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT 
code 30903. 
 
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 30903 is Control nasal hemorrhage, anterior, complex 
(extensive cautery and/or packing) any method. 
 
We find that CPT code 30903 is not supported in the medical record. Specifically, the medical records indicate 
a control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method was performed. 
There is a more appropriate CPT code for the service performed. Based on this information, we decided that 
Medicare rules for coverage of CPT code 30903 have not been met. Therefore, we decided that the Plan does 
not have to pay for Current Procedural Terminology (CPT) code 30903 provided on July 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 1, 2020, to January 22, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the services that the enrollee received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says custodial care services are not 
covered. 
 
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 services. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. 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 required 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from January 1, 2020, to January 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on November 2, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the copayment is being applied to 
an annual exam. You say that you did not expect to be billed for a follow up. The Plan denied your request. The 
Plan says the copayment applied 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 $20 
copayment in a physicians office. 
 
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you 
were also seen for a rash and laboratory tests were ordered. 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 office visit provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 25, 
2019. 
 
You asked the Plan to pay for the services. You say that the best efforts were made to meet the requirements. 
The Plan denied your request. The Plan says disputes are to be received within 120 days from the date of the 
claim determination. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the diagnoses listed were hyperlipidemia, elevated blood pressure, and encounter for general adult 
medical examination without abnormal findings. CMP, CBC, A1C, lipid panel, hepatitis panel, treponema 
screen RPR, HIV, and TSH were ordered. No other progress notes or documentation is provided to explain the 
context of these tests. Therefore, without sufficient supportive information provided, these tests will be 
considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional sedation services (99153) provided on June 17, 
2020. 
 
You asked the Plan to pay for additional sedation services. You say that this service is supported in the records. 
The Plan denied your request. The Plan says this service is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of "3" designates technical component only codes. A/B MACs (B) may not pay for 
the technical component (TC) of radiology services furnished to hospital patients. 
 
We looked at the file and Medicare rules. The service at issue has a Professional Component (PC)/Technical 
Component (TC) Indicator of "3." The record indicates that this service was provided in a hospital, meaning 
technical components cannot be paid. Based on this information, we decided that Medicare rules for coverage 
of additional sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
additional sedation services (99153) provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services received on November 7, 2019. 
 
You asked the Plan to pay for the medical services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the case file submitted to Maximus by the Plan 
was largely incomplete. Required documentation is missing. There is no documentation in the case file to 
support why this claim was denied. Therefore, we decided that the Plan has to hold you harmless for the 
medical services received on November 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services from 11:11 am on June 22, 
2020, to June 23, 2020. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says the enrollee's 
emergency medical condition was stabilized by 11:10am on June 22, 2020. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
 
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 inpatient services. Our physician 
reviewer found that the enrollee presented to the emergency room after falling and hitting his face on a brick in 
his garden. He sustained a comminuted frontal bone fracture and was admitted as a trauma patient. By June 22, 
2020, at 11:10 am, per the physician progress note, the enrollee was noted to be hemodynamically stable, 
afebrile, and had no acute events overnight. A repeat computed tomography (CT) scan of the head was 
negative. The review indicates that all inpatient care provided after 11:11 am on June 22, 20202, to discharge, 
was not needed at a non-plan facility. Neurosurgery had performed a consult evaluation on the enrollee. He 
noted the enrollee was found to have a right frontal sinus fracture and right orbital bone fracture. There was no 
acute neurosurgical intervention needed or repeat imaging needed. The post-stabilization care services at the 
non-plan facility were not medically necessary or reasonable. The treating physician did not document (in the 
physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of 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 the inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient hospital services from 11:11 am on June 22, 2020, to June 23, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the 
enrollee on May 22, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the level of service is more appropriate for CPT 99284. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 
99285 is an evaluation and management (E&M) code. In order to bill CPT 99285 a comprehensive history, 
comprehensive examination and high-complexity medical decision making must be documented. The provided 
documentation shows a comprehensive history and comprehensive examination, but not high-complexity 
medical decision making. The enrollee had a single complaint with stable vitals and non-actionable testing. The 
enrollee was discharged home, having been found to have no acutely life or limb threating condition. The 
billing of CPT 99285 is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (CPT 99285) provided to the enrollee on May 22, 2020.
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 IRF care is medically necessary to provide the 
enrollee with the quality treatment and management needed to access her physical abilities adequately. The 
Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan 
says that the enrollee can safely receive the services needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for congestive heart failure and was discharged home on March 6, 2021 with home health 
services. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair repair. 
 
You asked the Plan to pre-approve a shower chair. You say that a shower chair is medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair repair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Onglyza 5 mg tablet. 
 
You asked the Plan to pre-approve Onglyza. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug does not fall under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Onglyza 5 mg tablet.  
 
Benefits for Onglyza may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on September 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered when specific criteria are met.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered when specific criteria are met.

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had an elevated prostate specific antigen (PSA). He underwent a prostate biopsy on September 22, 2020 that showed a hypoechoic area on the left and a very large gland at 165 cc. The records do not support that the enrollee is being considered for a repeat biopsy due to persistent or elevated cancer risk factors; therefore, the ConfirmMDx testing does not meet criteria for coverage and was not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on September 22, 2020.