Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that you have tried and failed one shot and oral iron. 
You say that you were advised an iron drip would keep your ferritin level above 70 which is necessary to keep 
your restless leg syndrome symptoms at bay. You also say that this is the only thing that has worked for you 
and lasts about 3 years. The Plan denied your request. The Plan says the requested drug is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Injectafer. Our reviewer says that the 
request for Injectafer is not medically necessary. Our physician reviewer found the file indicates that the 
enrollee's levels are normal. The reviewer found that the requested use of Injectafer is not approved by the 
Food and Drug Administration (FDA) for the enrollees diagnosis. Its use is not supported by one of the major 
drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the 
reviewer found that the request for Injectafer is not medically reasonable or 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 13, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says this claim has been billed with missing 
information required by Medicare billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must enter the appropriate DEX Z-
CodeTM identifier on the claim for molecular testing. This code was not included in the claim submitted. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee fully meets the Medicare 
guidelines for LTACH admission. The Plan denied your request. The Plan says the Medicare guidelines for 
LTACH admission were not met and the enrollee can receive the services they need in another setting such as 
at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically necessary at this time. Completion of treatment at the current facility is recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) without contrast 
followed by with contrast, breast; bilateral (C8908). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has chronic right breast pain. You say 
that the enrollee reports that it has gotten slightly worse. You say that an MRI and ultrasound were discussed. 
You also say that the enrollee feels they may be able to tolerate an MRI. The Plan denied your request. The 
Plan says the requested MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found the standard workup for breast 
symptoms including patients with prior cancer includes mammography and ultrasound. The reviewer found 
that experienced breast imaging centers patients with discomfort can be gently imaged with both 
mammography and ultrasound and prior to proceeding to MRI conventional imaging is necessary to determine 
if MRI is necessary. Therefore, the reviewer found that the requested MRI is not medically reasonable or 
necessary at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) without contrast followed by with contrast, breast; bilateral 
(C8908).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 16, 2022, billed with 
codes 81210, 81272, 81292, 81295, 81298, 81301, 81317, 81194, and 81206. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 16, 2022, billed with codes 81210, 81272, 81292, 81295, 81298, 81301, 81317, 81194, and 81206.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement of a fixed partial denture (D6930) provided by 
a participating provider on May 19, 2022. 
 
You asked the Plan to pay for the re-cement of a fixed partial denture. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cement of a fixed partial denture (D6930) provided by a participating provider on May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), an 
adult prophylaxis (D1110), and complete intraoral series x-rays (D0210) provided on March 2, 2022. 
 
You asked the Plan to pay for a periodic oral evaluation (D0120), bitewings (D0274), an adult prophylaxis 
(D1110), and complete intraoral series x-rays (D0210). You say that you were informed before switching from 
your old plan that you can still request for dental reimbursement for dental works. You also say that now you 
have received a denial for your reimbursement request for dental. The Plan denied your request. The Plan says 
the member must receive services at a participating provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation (D0120), bitewings (D0274), an adult prophylaxis (D1110), and complete intraoral series x-rays 
(D0210) provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray services provided on May 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that the procedure was rendered in the 
appropriate place of service. The Plan denied your request. The Plan says the claim was billed with an 
inappropriate place of service. 
 
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 the x-ray services were billed with an outpatient place of service code. The claim information 
shows that the enrollee was an inpatient at the time the services were provided.  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 chest x-ray services provided on May 17, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network skilled nursing facility (SNF)
services.
You asked the Plan to provide coverage for these services. You say that at the time of the appeal SNF care was
medically necessary. The Plan denied your request. The Plan says out of network care was not shown to be
necessary. Maximus overturned the Plans denial stating SNF services were appropriate. The Plan requested a
reopen and stated that the records do not show out of network SNF services were required.
The Plan is correct in this case. 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 provide coverage for care from out-of-network
providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by
network providers.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide SNF services at issue in this appeal. We found no exception that would require the Plan to
provide coverage for these services out of network. Therefore, we decided that the Plan does not have to
provide coverage for out of network skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gene panel testing provided on April 8, 2022. 
 
You asked the Plan to pay for the testing services. You say that the documents support medical necessity. The 
Plan denied your request. The Plan says that the claim was billed with an inconsistent date of service. 
 
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. 
 
We looked at the file and the rules. The plan denied services as the billed date of service was not valid. 
However, the Plan has not shown that the specimen obtained did not meet one of the exceptions for the billed 
date of service. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the gene panel 
testing provided on April 8, 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: ER
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on December 19,
2021 and coded as 99053.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan showed that codes 99291
and 93010 were denied a lack of records. Those records have now been received and these codes have been
routed to the correct team for review. Codes 99291 and 93010 were paid by the on March 21, 2022, with check
number M1673003 which is prior to the Maximus decision date of May 17, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. Code 99053 has a status
indicator of B on the Physician Fee Schedule. This means that code 99053 is not separately payable. In
addition, the Plan has confirmed codes 99291 and 93010 were paid.
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on
December 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on July 20, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you are on a fixed income and cannot 
afford to pay the 20% coinsurance for the DME, which you say you have not yet received as of August 5, 2022. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.  
 
You have been asked to pay a coinsurance of $388.10, which is 20% of the allowed amount for DME 
($1,940.51 allowed x 20% = $388.10). This item/service falls within the Durable Medical Equipment (DME) 
and Related Supplies 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 DME 
provided on July 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay this claim as billed for services provided on July 20, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial for lack of information in the case file regarding those codes handled separately. The Plan requested a
reopen and provided the required information. The Plan provided documentation to show codes A0428, A0425,
and A0422 were overturned for clerical error and paid on February 1, 2022.
The Plan follows Medicare rules. Medicare rules say that fee schedule payment for ambulance transportation
and mileage is considered payment in full for ambulance services. No other payment can be made for
separately billed items or services. The other billed services are included in the payment made for the base code
and mileage code. In addition, the Plan has paid the remaining codes in dispute. Therefore, we decided that the
Plan does not have to pay for physician services provided to the enrollee on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for anesthesia services provided on July 27, 2021, charged by your out of network provider.
You asked the Plan for to pay for these services in full. You do not believe this bill is correct. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit by your provider.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible.
The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the coinsurance for anesthesia services provided on March 17, 2021, charged by your out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the single-photon emission computerized
tomography (SPECT) scan of the heart, cardiovascular stress test, Technetium and Regadenoson injection
provided on October 13, 2021.
You asked the Plan to reduce the cost sharing for the single-photon emission computerized tomography
(SPECT) scan of the heart, cardiovascular stress test, Technetium and Regadenoson injection. You say that you
already paid the $110 copayment and are now being billed for additional charges. 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 20%
coinsurance for each Medicare-covered Part B drug, a $110 copayment for radiological diagnostic services,
including SPECT scans and a $25 copayment for non-radiological diagnostic services, including stress tests.
You have been asked to pay a 20% coinsurance for the Technetium and Regadenoson injection. The
Technetium and Regadenoson injection are considered Part B drugs are not considered packaged codes. This
item/service falls within the Medicare-covered Part B drug benefit category. You have been asked to pay a
$110 copayment for a SPECT scan. You have also been asked to pay a $25 copayment for a stress test. A
SPECT scan and a stress test fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies
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 cost sharing for the single-photon emission
computerized tomography (SPECT) scan of the heart, cardiovascular stress test, Technetium and Regadenoson
injection provided on October 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the in-home care provided to the enrollee from April 27,
2020, to May 30, 2020.
You asked the Plan to pay for the in-home care. You say that the enrollee was forced to hire caregivers for
home care because no rehabilitation centers would admit him due to COVID-19. The Plan denied your request.
The Plan says that this service is not a benefit under the enrollee's plan. The Plan also says that the records do
not show evidence of receipt of prior authorization or certification of home health services.
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 looked at the file and Medicare rules. The documentation does not include a
valid prescription for these services. The agency used for these services provides companion care and not
licensed nursing or therapy care. Based on this information, we decided that Medicare rules for coverage of the
in-home care have not been met. Therefore, we decided that the Plan does not have to pay for the in-home care
provided to the enrollee from April 27, 2020, to May 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 25, 2021.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly
denied. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not
apply the correct billing criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines
that have been determined to be exact duplicates of another claim or claim line are denied. The Plan provided
documentation to show the services at issue were reimbursed by the Plan on November 02, 2021, with check
number L3517781. There is no evidence presented to support that the billed items/services were provided twice
on the same date. Based on this information, we decided that the Medicare rules for this claim have not been
met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on
August 25, 2021.