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

 
We decided that the Plan does not have to waive the cost sharing for the denosumab injection and the drug 
administration provided by an in-network provider on October 20, 2022. 
 
You asked the Plan to waive the cost sharing for the injection and the administration. You say that you never 
had to pay for these services 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 a 5% 
coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer, 
and a $100 copayment for in-network Medicare-covered surgery or other services at an outpatient hospital or 
ambulatory surgical center, including but not limited to hospital or other facility charges and physician or 
surgical charges. 
 
You have been asked to pay a $67.53 coinsurance for the injection ($1350.60 allowed amount x .05 = $67.53). 
This item/service falls within the Medicare Part B prescription drugs benefit category. You have also been 
asked to pay a $56.78 copayment for the drug administration because the allowed amount for this service is less 
than the $100 copayment. This item/service falls within the outpatient surgery and other medical services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit category. You have been asked 
to pay a total cost share of $124.31 for the injection and the administration ($67.53 + $56.78 = $124.31). 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 cost sharing for the denosumab injection and the drug administration 
provided by an in-network provider on October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services for drug testing provided on October 20, 2022. 
 
You asked the Plan to pay for lab services for drug testing. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services for drug 
testing provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on July 25, 2022. 
 
You asked the Plan to pay for a specialist visit. You say that the providers staff said they were in-network and 
that the visit would be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a specialist visit 
provided on July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on August 4, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
procedure code 99233 provided on August 4, 2022. The Plan denied your request. The Plan says the medical 
records do not support the billing of procedure code 99233 provided on August 4, 2022. 
 
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 asked our coder 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 procedure code 99233. Our reviewer says that the medical 
records do not support the billing of procedure code 99233 provided on August 4, 2022. Our reviewer found 
the review indicates that the enrollee was with a history of dementia, aortic stenosis, hypertension (HTN), and 
hyperlipidemia (HLD) who was admitted with weakness and syncope. Current Procedural Terminology (CPT) 
code 99233 was not supported. This 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. The review has determined that the medical records did not 
support a detailed interval history. The medical records did support a detailed examination. The medical 
records did not support medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on August 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) home health service visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five (5) home health service visits (G0299).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 87503, 87632, 87634 and 87801-XU
provided to the enrollee on January 12, 2022.
You asked the Plan to pay for these codes. You say that these services were necessary and were billed
correctly. The Plan denied your request. The Plan says that these services were not billed in accordance with
Medicare guidelines. Maximus partially overturned the Plan's denial. The Plan requested a reopening stating
that Maximus did not apply the correct Medicare rules.
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 87634 is a column II code to column I code 87632. 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 for code 87634. Medicare rules also state that code 87632 is non-covered by
Medicare.
We asked our coder 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 codes. Our reviewer says that that procedure codes
87503, 87634 and 87801-XU are not supported. Procedure code 87503 has been billed following Medicare
rules as procedure code 87502 should be billed in conjunction with 87503. In addition, it is highly unlikely that
more than one unit of 87503 would be billed for a single date of service, but more than one unit was billed.
Medical documentation does not support the reported quantity. In addition, procedure code 87801-XU is a
column II code to column I code 87632. Although this service was billed with a modifier to bypass this edit,
the use of this modifier is not properly supported and documented to override the edit. Our reviewer found that
the enrollee's condition does not meet criteria for coverage of procedure codes 87503, 87634 and 87801-XU.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these codes have not been met. Therefore, we decided that the Plan does not
have to pay for procedure codes 87503, 87632, 87634 and 87801-XU provided to the enrollee on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that the facility wants you to stay 
long-term but has never provided you with a wheelchair. The Plan denied your request. The Plan says this 
feature is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that due to the critical clinical value of the testing 
that benefits the enrollee, you request reconsideration for the requested testing. The Plan denied your request. 
The Plan says the request does not meet Medicare rules because expanded panel testing is only indicated when 
targeted panel testing is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The medical records indicate targeted testing has not been performed 
to determine a possible etiology prior to expanded testing. Medicare says that testing is ordered by a clinician 
specialist in Infectious Diseases or Pulmonology for an enrollee with severe and established underlying 
respiratory pathology and treatment with antibiotics. The records also show that testing was not ordered by a 
clinician specializing in Infectious Disease or Pulmonology nor does the enrollee have an established 
underlying respiratory pathology as outlined by the policy. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization with angioplasty, atherectomy, and 
stent placement (37220, 37224, 37225, 37228, 37229, 37221, 37226, and 37227). 
 
You asked the Plan to pre-approve revascularization with angioplasty, atherectomy, and stent placement. You 
say that the requested revascularization with angioplasty, atherectomy, and stent placement is medically 
necessary. The Plan denied your request. The Plan says the requested revascularization with angioplasty, 
atherectomy, and stent placement is 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 revascularization with angioplasty, 
atherectomy, and stent placement. Our reviewer says that the requested revascularization with angioplasty, 
atherectomy, and stent placement is not medically necessary. Our physician reviewer found it is documented 
that the enrollee presented for evaluation of bilateral leg swelling with ecchymosis. It is documented that she 
has a history of chronic pain and lower back pain and spends most of her days with her legs elevated in the bed. 
She admits to shortness of breath that occurs with minimal physical activity. The initial plan was to obtain 
ankle brachial index (ABI) tests however these are not in the medical records provided. The angiographic findings are not consistent with limb threatening ischemia. There is a lack of clarity with respect to the 
enrollees symptoms and not clear that the enrollees walking limitations are due to vasculogenic claudication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization with angioplasty, atherectomy, and stent placement have not 
been met. Therefore, we decided that the Plan does not have to pre-approve revascularization with angioplasty, 
atherectomy, and stent placement (37220, 37224, 37225, 37228, 37229, 37221, 37226, and 37227).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on September 13, 2022. 
 
You asked the Plan to pay for telehealth services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on September 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laryngoscopy provided on May 09, 2022. 
 
You asked the Plan to pay for the laryngoscopy. You say that the services should be covered under medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laryngoscopy 
provided on May 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on November 03, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that it is the responsibility of the facility 
to obtain referrals. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on November 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on May 5, 2022. 
 
You asked the Plan to pay for the panel testing. You say that the enrollee was in an emergency situation. The 
Plan denied your request. The Plan says a panel test must not be unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 

We find that a respiratory pathogen panel of more than 5 pathogens was provided. Panels with more than 5 
pathogens is not medically necessary. Furthermore, a panel test is a single service with a single unit of service.  
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the respiratory pathogen panel provided on May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labratory services provided on September 23, 2022. 
 
You asked the Plan to pay for labratory services. You say that this was a short notice case so we had no time to 
get preauthorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for labratory services 
provided on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 09, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
October 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood glucose monitor (E0607), and test strips 
(A4253). 
 
You asked the Plan to pre-approve a blood glucose monitor, and test strips. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC 
are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a blood glucose monitor, and test strips. Therefore, we decided that the Plan does not have to pre-approve a 
blood glucose monitor (E0607), and test strips (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on November 23, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on November 23, 2022.