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

 
We decided that the Plan does not have to pre-approve a replacement Continuous Positive Air Pressure (CPAP) 
machine (E0466). 
 
You asked the Plan to pre-approve the replacement CPAP machine. You say that the replacement CPAP is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Coverage of CPAP is initially limited to a 12-week 
period to identify beneficiaries diagnosed with OSA who benefit from CPAP. CPAP is subsequently covered 
only for those beneficiaries diagnosed with OSA who benefit from CPAP during this 12-week period. 
 
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 replacement CPAP machine. Our 
reviewer says that the new CPAP machine is not medically necessary. Our physician reviewer found the age of 
the old device is not documented. If it is less than 5 years, documentation is needed from the vendor that it is 
beyond repair. This documentation is not included in the case file. If the device is part of a manufacturer's 
recall, the replacement device should be obtained from the manufacturer. 
 
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 replacement CPAP machine have not been met.  
 
  
Therefore, we decided that the Plan does not have to pre-approve a replacement Continuous Positive Air 
Pressure (CPAP) machine (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (60811) provided November 4, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is not separately payable. 
 
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 CPT code 60811 is not supported in the medical record. Specifically, the code billed is included in 
the 90-day global surgery period for code 60811 that was billed on November 2, 2021. Based on this 
information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, 
we decided that the Plan does not have to pay for surgical services (60811) provided November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the foot inserts provided on August 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that the orthotics were recommended to manage 
pain. The Plan denied your request. The Plan says that the enrollee does not have diabetes and the insert is not 
an integral part of a brace. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The services were provided by a contract provider. The file does not show that the plan provided notice that the 
services provided would not be covered. For a service or item that is normally not covered, but could be 
covered under some conditions, the EOC alone is not adequate notice of non-coverage. Under Medicare rules, 
this means the services provided is considered approved by the plan. Therefore, we decided that the Plan has to 
pay for the foot inserts provided on August 23, 2021.  
 
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 medical services provided on November 3, 2021. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument for coverage. The 
Plan denied your request. The Plan says you did not provide medical records to support the medical necessity 
of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of medical services provided on 
November 3, 2021. have been met. Despite several requests, you have failed to provide any medical records supporting payment for the services in dispute. Therefore, we decided that the Plan does not have to pay for 
medical services provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), polarization (V2762), 
progressive lens (V2781), and polycarbonate or equal lens (V2784) provided on March 24, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, polarization, progressive lens, and polycarbonate or 
equal lens. You say that you are on a fixed income and cannot pay the entire amount for these services. The 
Plan denied your request. The Plan says you have exceeded the limits set in the subscriber agreement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames every 2 years. 
 
 
  We looked at the file and the Plan's rules. The record shows that you received glasses on March 19, 2022, and 
your standard lenses and frames benefit has been exhausted. Based on this information, we decided that the 
Plan's rules for coverage of the anti-reflective coating, polarization, progressive lens, and polycarbonate or 
equal lens have not been met. Therefore, we decided that the Plan does not have to pay for the anti-reflective 
coating (V2750), polarization (V2762), progressive lens (V2781), and polycarbonate or equal lens (V2784) 
provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service December 
22, 2021. 
 
You asked the Plan to pay for procedure code A4550. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code A4550 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued maintenance (months 37-60) for an oxygen 
concentrator for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says after 36 months, the vendor is required to provide contents and services. 
 
The Plan must follow Medicare rules. The rules say the the vendor is responsible for oxygen equipment 
maintenance after month 36. 
 
The plan is not required for pay for these services as the request is for after the 36th month of rental. 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 pre-approve continued maintenance (months 37-60) for an oxygen 
concentrator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniSeq Insight panel testing received on December 22, 
2021. 
 
You asked the Plan to pay for the OmniSeq Insight panel testing. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that testing identified with code 81455 is not covered. 
 
We looked at the file and Medicare rules. The testing at issue is identified with code 81455. This code is 
specifically not covered. Based on this information, we decided that Medicare rules for coverage of the 
OmniSeq Insight panel testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the OmniSeq Insight panel testing received on December 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for mental health office and telehealth visits 
provided from December 1, 2021, to December 21, 2021. 
 
You asked the Plan to reduce the copayments for the mental health visits. You say that your copayments should 
only be $15 for these services. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $35 
copayment for each in-person therapy visit and a $30 copayment for each telehealth therapy visit.  
 
You have been asked to pay a $35 copayment for the in-person therapy visit provided on December 1, 2021. 
You have also been asked to pay a $30 copayment for the telehealth therapy visit provided on December 21, 
2021. The total for both visits is $65. The mental health visits fall within the Outpatient Mental Health Care 
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 reduce the copayments for mental health office and 
telehealth visits provided from December 1, 2021, to December 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound biopsy provided on January 
31, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound biopsy. You say that you were unaware of this 
copayment prior to the service and therefore feel you should not need to pay for it. The Plan denied your 
request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $375 for Medicare-covered outpatient hospital services.  
 
You have been asked to pay the allowed amount of $370 which is less than the $375 copayment for an 
ultrasound biopsy. An ultrasound biopsy falls within the Medicare-Covered Outpatient Hospital Services 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound biopsy provided 
on January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is 
experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Food & Drug Administration (FDA) states that the Vertiflex procedure is contraindicated if 
the enrollee has a body-mass index greater than 40. The record indicates that this enrollee has a body-mass 
index greater than 40. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection provided to the enrollee on 
December 9, 2021. 
 
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 Current Procedural Terminology (CPT) code 87651 (1 Unit) remains not supported. 
 
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 87651 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Streptococcus, group A, amplified probe technique." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined that 
the records support that CPT 87651 - Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, 
group A, amplified probe technique - was not rendered in this case. CPT 87651 is not the most appropriate 
code to use in this case. 
 
We looked at this coder'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 infectious agent detection provided to the enrollee on December 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for Euflexxa.  
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 Euflexxa. Our reviewer says that the 
enrollee does not meet criteria for Euflexxa. Our physician reviewer found based on the medical records 
provided there is no documentation that the Euflexxa at issue in this case meets Local Coverage Determination 
(LCD): Hyaluronan Acid Therapies for Osteoarthritis of the Knee (L35427) criteria. Provided records do not 
document radiographic imaging to support the diagnosis of osteoarthritis as the etiology of the enrollee's knee 
pain as required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87640, 87653, 87798, 87801) 
provided on October 14, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services should be covered. The Plan 
denied your request. The Plan says these services are not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services (87481, 87640, 
87653, 87798, 87801) provided on October 14, 2021. have been met. The submitted records consist only of order information for the laboratory tests provided on October 14, 2021. 
No results or other documentation have been provided to show that the testing was provided and medically 
necessary. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87640, 
87653, 87798, 87801) provided on October 14, 2021.
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 care. The Plan denied your request. 
The Plan says the enrollee does not meet 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on March 
23, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you have the same exam every year 
and were never billed $40. The Plan denied your request. The Plan says you had a Medicare-covered eye exam 
rendered on this date of service. 
 
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 $40 
copayment for Vision care.  
 
 
  You have been asked to pay a $40 copayment for the eye exam. This eye exam falls within the Medicare-
covered Vision care benefit category. The record shows that you received a medical eye exam on this date of 
service. 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 eye exam (92014) provided on March 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement of subcutaneous tissue 
provided from January 4, 2022, to January 18, 2022. 
 
You asked the Plan to waive the copayment for wound debridement of subcutaneous tissue. You say that that 
you were told that you could not receive home wound care because you were doing outpatient physical therapy. 
You were also told that home wound care would not be approved. You also say you were not told that this 
facility was an outpatient clinic and required a $100 copayment per visit. The Plan denied your request. The 
Plan says you were charged the correct cost sharing amount. 
 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 $100 
copayment for 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 $100 copayment for each wound debridement of subcutaneous tissue for three 
visits, which is a total of $300 ($100 x 3 = $300). Wound debridement of subcutaneous tissue provided falls 
within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 wound 
debridement of subcutaneous tissue provided from January 4, 2022, to January 18, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.