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

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the medical necessity of a TTE, in the absence of any cardiac symptoms or 
abnormalities on physical examination. Clinical guidelines do not support performing a TTE in this setting. In 
summary, there is no supportive evidence for the medical necessity of a TTE in this enrollees clinical 
management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE) (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary because the 
enrollee is receiving the care they need in the hospital where they are now and there is no need to transfer to the 
LTACH currently. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wearable, automatic, external defibrillators (AED) with 
integrated electrocardiogram analysis (K0606) provided on October 31, 2021. 
 
You asked the Plan to pay for the AED. You say that the item was medically necessary for the enrollee. You 
also say the enrollee was in dire need of this potentially life-saving device. The Plan denied your request. The 
Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the AED was not filed until November 7, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the wearable, automatic, external defibrillators (AED) with integrated 
electrocardiogram analysis (K0606) provided on October 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on March 14, 2022.
You asked the Plan to pay for the laboratory services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the required unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve a CPAP device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP therapy. 
 
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 a CPAP device. Our reviewer says that 
the member does not need this item. Our physician reviewer found the patient is not using the device every day. 
There is no compliance report or documentation that the patient's current device is inoperable and unrepairable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on December 1, 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 overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan provided documentation to show that per the National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edits, a PTP edit does indeed exist between 00560 (a column 1 code and 93355 (a column 2 code) which cannot be bypassed by using a modifier as the modifier indicator in the guidelines is "0".
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. This claim could not be paid as billed due to the PTP edit which exists between the codes billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial denture - resin base (D5211) provided on 
November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 16, 2021. Therefore, 
we decided that the Plan does not have to pay for maxillary partial denture - resin base (D5211) provided on 
November 29, 2022.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to lower the copayment for SNF. We decided that the Plan does not have to waive 
the copayment for SNF.  
 You asked the Plan to waive the copayment for skilled nursing facility (SNF) provided on November 1, 2022, 
to November 29, 2022. You say that you disagree with the copayment. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to lower the copayment for SNF.  
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. Your contract with the Plan says that enrollees must pay a $2,398.76 copayment for 
SNF 
 
Based on the Plan contract, however, you cannot be asked to pay more than a $188 copayment per day for days 
21-100 for SNF which is $1,692 ($188 x 9 days = $1,692).  
 
Therefore, we decided that the Plan has to lower the copayment for SNF.  
 
We also decided that the Plan does not have to waive the copayment for SNF. 
 
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 $0 
copayment per day for days 1-20 and a $188 copayment per day for days 21-100 for SNF. Therefore, we 
decided that the Plan does not have to waive the copayment for SNF. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic mattress. 
 
You asked the Plan to pre-approve the orthopedic mattress. You say that this mattress is medically necessary. 
The Plan denied your request. The Plan says there is no record of a hospital bed being provided. This mattress 
is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
and expandable controller, harness, electronic connection. 
 
You asked the Plan to pre-approve the power wheelchair and upgraded electronics. You say that you are 
requesting an appeal for this enrollee's power rehab chair. The enrollee has significant pain using the manual 
wheelchair. The Plan denied your request. The Plan says the records show that the enrollee has another 
wheelchair that meets the enrollee's needs. 
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: a neurological condition, myopathy or congenital 
skeletal deformity.  
 
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 power wheelchair and upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records do not support that the enrollee is 
high risk for skin breakdown (records report the enrollee is at moderate risk) or has a history of pressure ulcers 
or has had skin flap surgery. Although records document the enrollee performs bladder self-catheterization 
there is documentation that the enrollee is able to transfer from wheelchair to bed independently. Records do 
not document that the enrollee has increased muscle tone or spasticity (tone is reported as hypotonic) to meet 
criteria for the single power option wheelchair with power recline. The provided records document that the 
enrollee has bilateral within functional limits upper extremity function and range of motion and is independent 
with dressing, grooming, feeding, meal preparation and toileting, thus indicating the enrollee has adequate 
upper extremity strength and function to operate the wheelchair's power options with 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 the power wheelchair and upgraded electronics have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
and expandable controller, harness, electronic connection.
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 the enrollee's conditions require a higher level of 
physician oversight to optimize the enrollee's rehab outcomes. The Plan denied your request. The Plan says the 
enrollee's medical and therapy needs can be met at a less intensive level of care. 
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) 
provided on November 14, 2022. 
 
You asked the Plan to pay for CGM supplies. You say that the enrollee needs these supplies. The Plan denied 
your request. The Plan says the provided documentation submitted does not sufficiently support the billed 
supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case for the date of service in this case. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) 
provided on November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to waive the $50 copayment charged for imaging services provided on November 3, 2022.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the claim history shows that in 2021 you were a member of the Plans PPO plan which had a zero-dollar copayment for this type of service. For the 2022 Plan year, you enrolled in the HMO plan which requires a $50 copayment for this type of service
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. Your contract with the Plan clearly says that you must pay $50 copayment for radiological diagnostic services.
You have been asked to pay the correct amount based on your 2022 contract with the Plan which is different from your 2021 contract. 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 share charged for imaging services provided on November 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (22869 
and 22870). 
 
You asked the Plan to pre-approve the surgical services. You say that your pain has increased, and you are not 
able to get up and do anything because of the pain. The Plan denied your request. The Plan says the services 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 the surgical services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertilfex device is experimental. More research is needed. 
 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex superion device placement surgery (22869 and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exam focused on a certain problem (D0140), an x-ray 
(D0220) and a nerve treatment on a molar tooth (D3330) provided on April 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an exam, x-ray, and a nerve treatment. You say that this should be covered. The 
Plan denied your request. The Plan says OON providers are 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for exam focused on a certain problem (D0140), an x-
ray (D0220) and a nerve treatment on a molar tooth (D3330) provided on April 5, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT scan (D0365) and a consultation (D9310) 
provided on January 10, 2023. 
 
You asked the Plan to pay for CT scan and a consult. You say that these services should be covered. The Plan 
denied your request. The Plan says these are not covered services. 
 
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 cone 
beam CT scan (D0365) and a consultation (D9310) provided on January 10, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paclitaxel protein-bound. 
 You asked the Plan to pre-approve Paclitaxel protein-bound. The Plan denied your request. The Plan says the 
enrollee has not failed Taxol or Taxotere. 
 
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 Paclitaxel protein-bound. Our physician 
reviewer found that the enrollee has breast cancer. The requested medication is a new start. The provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's 
preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service 
cannot be 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 Paclitaxel protein-bound have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Paclitaxel protein-bound.