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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0427) 
provided on December 22, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $150 
copayment for Ambulance Services.  
 
 
  You have been asked to pay a $150 copayment for the ambulance transportation services. 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 ambulance transportation services (A0427) provided on December 
22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telomerase reverse transcriptase (TERT) gene analysis 
testing provided on October 25, 2021, billed with code 81345. 
 
You asked the Plan to pay for the TERT testing as billed. You say that this should be paid in full. The Plan 
denied your request. The Plan says payment was made for code 0089U, but 81345 was not billed with the 
required modifier. 
 
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 81345 
is a column II code to column I code 0089U. 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 the telomerase reverse transcriptase (TERT) gene analysis testing 
provided on October 25, 2021, billed with code 81345.
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 are going to need IRF care to help you walk. 
You say that you lose your balance when walking and need assistance with a walker as well. You say that you 
were recommended for 7-14 days of IRF care that would greatly impact your walking and quality of life. The 
Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that the enrollee 
can safely receive the services needed in other settings. 
 
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 [state the medical finding(s) upon which the physician based his/her conclusion] 
 
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 pre-approve two vestibuloplasties (D7340 x2) and therapeutic 
parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the vestibuloplasties and therapeutic parenteral drugs. You say that you 
need surgery in order to get dentures, but you cannot afford it. The Plan denied your request. The Plan says 
these services are not covered expenses under your dental plan. 
 
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 pre-approve two 
vestibuloplasties (D7340 x2) and therapeutic parenteral drugs (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electronic connection (E2311). You say that the requested expandable controller (E2377), expandable 
controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick are medically necessary. The Plan denied your request. The Plan says 
the requested expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are 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 an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311). Our reviewer says that the 
requested expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically 
necessary. Our physician reviewer found the enrollee does not require a separate display (i.e., for alternate 
control devices), other electronic devices (e.g., control of an augmentative speech device or computer through 
the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power 
elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's 
right upper extremity strength and function of supervision with set up assist feeding support that the enrollee 
can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the record indicates that the enrollee requires acute critical care services as he is still 
on the ventilator due to aspiration pneumonia and is not able to be weaned. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. 
 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to waive the copayments charged for services provided from June 3, 2021,
to July 12, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct and you
would like a refund for these services. The Plan denied your request. The Plan says this cost share was charged
based on the services provided and the Plan contract agreement. Maximus administratively overturned the
Plans denial because the case file lacked a plan contract agreement. The Plan requested a reopen and provided
the required contract for review.
The Plan is correct in this case. 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 $15 copayment for each outpatient therapy visit.
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 copayments charged for services provided from June 3, 2021, to July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
November 30, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you feel you were not 
in a position to ask these doctors if they were in-network, if you had been, you would have asked for doctors 
in-network or changed hospitals. 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 $450 
copayment per day, days 1 to 4 for in-network, inpatient hospital care.  
 
 You have been asked to pay a $450 for inpatient hospital services. Inpatient hospital services fall within the 
inpatient hospital care benefit category. The record shows that this provider was in-network at the time 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 inpatient hospital services provided from 
November 30, 2021, to December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning, all four quadrants. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the teeth must noticeable bone loss or show hard substance buildup. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the reason for the 
denial was that the criteria for coverage have not been met. A review of the documentation indicates that there 
are areas of pathological pocket depth according to the periodontal charting. However, the radiographs 
provided were not adequate to access bone loss or subgingival calculus buildup. The documentation provided 
was incomplete to meet the criteria for coverage for periodontal scaling and root planing in four quadrants 
(D4341). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve deep gum and root cleaning, all four quadrants.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis provided to the 
enrollee on December 22, 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 the cancer needs to be either recurrent, relapsed, refractor, metastatic, or advanced stay III or IV 
cancer and not been previously tested with the same test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found coverage is for recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. No staging 
is given for this patient, only that there is an FDG avid right upper lobe tumor with biopsy showing 
adenocarcinoma of the lung. Without staging, the medical necessity of molecular testing cannot be determined. 
The service is not reasonable or medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a targeted genomic sequence analysis provided to the enrollee on December 22, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan received on August 16, 2021. 
 
You asked the Plan to pay for the scan. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the scan was performed prior to the completion of antibiotics. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pay for the scan. Our reviewer says that the scan at 
issue in this case was medically reasonable and necessary. Our physician reviewer found you had a second 
course of antibiotics. The scan of 8/16/21 may have been a day or two early while you were still on antibiotics, 
but the scan would have been necessary anyway, as the articulated management plan was to do the second CT 
after antibiotics to see if cleared. The fact the scan was done perhaps a day or two prior to completing the 
antibiotics is meaningless as the scan was to have been done anyway. 
 
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 scan have been met. Therefore, we decided that the Plan has to pay for a 
computed tomography (CT) scan received on August 16, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (CPT code J7323). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy (multi-
injection) device(s): Orthovisc OR Supartz FX. The Plan states there is no indication our preferred agent(s) 
would likely be: less effective, and/or cause adverse effects for the enrollee. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the case file does not contain documentation that Orthovisc or Supartz FX have been tried and failed. 
The documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would 
likely have adverse effects 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa (CPT code J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on July 26, 2021, billed 
with codes 81206 and 81292. 
 
You asked the Plan to pay for the two billed codes of the panel. You say that this was medically necessary 
testing that is supported by literature. The Plan denied your request. The Plan says the rules say that panels 
must be billed with a single CPT code. Therefore, the Plan is only paying 11 of the 13 billed codes for this 
panel.  
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing 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 next-generation sequencing panel was not billed in accordance 
with Medicare rules. Based on this information, we decided that Medicare rules for coverage of the two billed 
codes of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus 
gene panel provided on July 26, 2021, billed with codes 81206 and 81292.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lift chair. 
 
You asked the Plan to pre-approve the lift chair. You say that the lift mechanism has been malfunctioning. You 
state that you have been calling the provider and have not had heard anything or received an order. You state 
you do not mind keeping this chair, but it needs the new mechanism. The Plan denied your request. The Plan 
says a lift chair is not medically necessary at this time because the requested lift chair serves essentially the 
same purpose as equipment already available to you and it was confirmed with the provider that they will be 
following up with you directly to schedule your repairs. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the lift chair have not been met. The lift chair serves essentially the same purpose as equipment already available to you. The Plan states the provider you were in contact with will 
be following up with you directly to schedule the needed repairs. Therefore, there is no need for a new lift 
chair. Therefore, we decided that the Plan does not have to pre-approve the lift chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided with 
drug testing on August 2, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this testing was 
medically necessary and should be paid. The Plan denied your request. The Plan says the drug testing was paid, 
but no separate payment is allowed for 83789. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided with drug 
testing on August 2, 2021, billed with code 83789.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from July 16, 2021, to 
July 22, 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 DRG 481 is more appropriate in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 480 (HIP AND FEMUR PROCEDURES 
EXCEPT MAJOR JOINT WITH MCC). We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found there was no specific evidence of metabolic encephalopathy. The review has 
determined that the medical records did not support the billing of toxic encephalopathy (G92).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from July 16, 2021, to July 22, 2021.