Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service March 1, 
2022. 
 You asked the Plan to pay for procedure code 99291. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 99291 is bundled into 
payment for code 32551. 
 
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 99291 
is a column II code to column I code 32551. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 99291 billed for date of service March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 2 Power Wheelchair.
You asked the Plan to provide coverage for this request. You say that the requested power wheelchair is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 2 power
wheelchair. The Maximus Physician Reviewer determined coverage was reasonable and necessary. The Plan
requested a reopen and argues that the home evaluation shows a power wheelchair cannot be accommodated.
The medical records show you have a medical history that includes stroke with mild right hemiparesis and left
below the knee amputation with mobility impairments. A Mobility Assistive Equipment - Face to Face
Examination Report dated November 16, 2021, documents that it is unknown whether you can safely maneuver
a power wheelchair in the home. A Home Evaluation dated March 24, 2022, documents that door width, levels,
ramp, and maneuver area within the home are not acceptable. The Plan is correct in this case. The available
documentation in the case file is insufficient to demonstrate all of the requir3es criteria for coverage of a Group
2 Power Wheelchair have been met.
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 request have not been met. Therefore, we decided that the Plan does not
have to provide coverage for a Group 2 Power Wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee is at risk for complications. 
The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G device. 
 
You asked the Plan to pre-approve the requested services. You say that the device can significantly reduce 
limitations. The Plan denied your request. The Plan says there is insufficient evidence to determine 
improvements in relevant outcome measures. 
 
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 the requested services. Our physician 
reviewer found that although records from the device manufacturer/vendor argue medical necessity of the 
requested device, records from the enrollee's actual treating provider do not clarify why the requested device is 
the most appropriate treatment for the enrollee's condition. In addition, the provided records report right upper 
extremity spasticity which may be a contraindication to use of the device. Based on the medical records 
provided and current clinical guidelines, there is no documentation that the MyoPro Motion G device at issue 
in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro Motion G device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound cleanser (A6260) provided on March 30, 2022. 
 
You asked the Plan to pay for a wound cleanser. You say that you disagree with the denial. You also say it was 
your understanding that the wound cleanser would be covered by the plan. The Plan denied your request. The 
Plan says the requested wound cleanser is not covered by the plan. 
 
The Plan must follow Medicare rules. Medicare rules say there are wound care items which are non-covered 
under the surgical dressing benefit because they do not meet the statutory definition for a dressing.  
 
We looked at the file and Medicare rules. Medicare rules say the requested wound care items are not covered 
by the plan. Based on this information, we decided that Medicare rules for coverage of a wound cleanser have 
not been met. Therefore, we decided that the Plan does not have to pay for a wound cleanser (A6260) provided 
on March 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 2, 2022. 
 
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 billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
April 2, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an esophagogastroduodenoscopy (43239) and colonoscopy (45380) 
billed for date of service June 28, 2022. 
 
You asked the Plan to pay for an esophagogastroduodenoscopy and colonoscopy. You say that the services at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that the claim or 
service at issue is a duplicate. 
 
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. Specifically, the Plan has not documented that the claims are duplicate claims in 
any respect other than location. It is the Plan's responsibility to substantiate its denial with evidence. In this 
case, the Plan's denial has not been substantiated, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for an esophagogastroduodenoscopy (43239) and colonoscopy (45380) billed for date of 
service June 28, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided from 
December 1, 2021, to December 8, 2021. 
 
You asked the Plan to pay for the billed services. You say that the claims are justified. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99233 is not supported in the medical record. Specifically, the records do not show that 
the enrollee was unstable or developed a significant complication. The records do not indicate that 35 minutes 
was spent with the enrollee. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation 
and management services provided from December 1, 2021, to December 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
You asked the Plan to provide coverage for SNF care. You say that at the time of the request, SNF services
were medically requested. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined these services to be necessary. The Plan requested a reopen and
stated that the medical records only show a need for distant supervision for dynamic sitting and grooming, and
required close supervision for static/dynamic standing, sit to stand, bathing, and upper/lower body dressing.
The enrollee required supervision to contact guard assist to ambulate 250 feet with a rolling walker. The Plan is
correct in this case. The records show no required skilled nursing services were identified. The documentation
does not support that it was medically reasonable and necessary to provide skilled therapy services to this
enrollee on a daily basis in a skilled nursing facility 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 provide coverage for skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 17, 
2021, to February 18, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found observation care would have been more appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 17, 2021, to February 18, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Caris Molecular Intelligence tumor testing provided on 
April 25, 2022. 
 
You asked the Plan to pay for the Caris Molecular Intelligence tumor testing. You say that the Caris Molecular 
Intelligence tumor testing was medically necessary. The Plan denied your request. The Plan says the Caris 
Molecular Intelligence tumor testing was 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 pay for the Caris Molecular Intelligence tumor 
testing. Our reviewer says that the Caris Molecular Intelligence tumor testing was not medically necessary. Our 
physician reviewer found the enrollee has a diagnosis of stage IV Malignant neoplasm of upper lobe, left 
bronchus or lung. The coverage criteria as established by NCD 90.2 have not been met in this case, as the 
laboratory test does not have FDA approval or clearance as a companion in vitro diagnostic, and an FDA-
approved or cleared indication for use in the enrollee's cancer. The available documentation does not support 
that Caris Molecular Intelligence tumor testing provided on April 25, 2022, was medically reasonable and 
necessary for the enrollee in this case. 
 
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 Caris Molecular Intelligence tumor testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Caris Molecular Intelligence tumor testing provided on April 
25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
January 10, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you feel as though the copayment was 
the incorrect amount. 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 $125 
copayment for Medicare-covered diagnostic procedures and tests in an outpatient hospital setting.  
 
You have been asked to pay a $113.94 copayment for an MRI. This item/service falls within the Medicare-
covered diagnostic procedures and tests in an outpatient hospital setting benefit category; however, you are 
only being charged $113.94 which is less than the required amount. 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 magnetic resonance imaging (MRI) January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 14-day sensor kit. You say that the enrollee monitors 
their blood sugar between 4 and 6 times a day. It is imperative that the enrollee use a continuous glucose 
monitor. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 14-day sensor Kit have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor 
kit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) billed for date of service December 17, 2021. 
 
You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that an MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. 
 
We find that code 70450 has an MUE of 3. The Plan has documented payment for 3 units of 70450 by 
providers at the same practice on the same date of service. Any further units are not supported. Based on this 
information, we decided that Medicare rules for coverage of a CT scan of the head or brain have not been met. 
Therefore, we decided that the Plan does not have to pay for a CT scan of the head or brain (70450) billed for 
date of service December 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the criteria for a continued SNF stay have not been met. Skilled 
services can be provided on an intermittent outpatient basis, in a long-term care facility, or at the home with 
home health care 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient visit (99204) provided on January 27, 2022. 
 
You asked the Plan to pay for the new patient visit. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, records show that the 
enrollee received services from the same physician group and by a physician of the same specialty previously. 
Records do not support that the enrollee was a new patient. Based on this information, we decided that 
Medicare rules for coverage of the new patient visit have not been met. Therefore, we decided that the Plan 
does not have to pay for a new patient visit (99204) provided on January 27, 2022.