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

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you shouldnt have to pay for this. 
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 $75 
copayment for Diagnostic procedures and tests. 
 
You have been asked to pay a $75 copayment for ultrasound. This item/service falls within the Diagnostic 
procedures and tests 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 ultrasound provided 
on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not 
obtained. 
 
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 a home visit provided on August 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair (PWC) with multiple 
power options (K0861) and related accessories. 
 
You asked the Plan to pre-approve the PWC and related accessories. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group three power wheelchair is covered if the 
beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or 
if the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is 
unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to 
safely operate the power wheelchair that is provided. 
 
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 PWC and related accessories. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found the records show the 
enrollee is unsafe using the power wheelchair and there is no evidence the enrollee's caretaker cannot manage a 
manual wheelchair. 
 
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 PWC and related accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a group three power wheelchair (PWC) with multiple power options 
(K0861) and related accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, skilled nursing facility services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Based on the medical records provided and the enrollee's diagnosis of Parkinson's Disease, the enrollees needs were custodial in nature, which is not covered by Medicare. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies and materials provided by the physician over 
and above those usually included with the office visit or other services rendered (97180) and the acupuncture 
treatments (97810 x 2) provided from April 1, 2022, through April 20, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the services at issue do not meet criteria 
for coverage. 
 
 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.  
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services at issue in this case were not 
provided on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the supplies and materials provided by the physician over and above those usually included 
with the office visit or other services rendered (97180) and the acupuncture treatments (97810 x 2) provided 
from April 1, 2022, through April 20, 2022.
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 enrollee was admitted with acute hypoxic respiratory failure in the setting of 
multifocal pneumonia from influenza and respiratory syncytial virus. The record indicates that the enrollee is 
improving but still requires continued acute care services before transitioning to a lower level of care. 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. The elements of the coverage rules 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve C3-C7 laminectomy with fusion. 
 
You asked the Plan to pre-approve C3-C7 laminectomy with fusion. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 C3-C7 laminectomy with fusion. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee was being treated for kyphosis of the cervical region; radiculopathy 
of the cervical region; carpal tunnel syndrome. The enrollee presented with bilateral hand paresthesias that 
seem to be a little worse at nighttime. The exam of the cervical spine reveals intact muscle strength. The 
enrollee states the arms feel weaker than they used to. The sensation and reflexes are intact.  
 
The enrollee has had previous cervical decompression and fusion at C5-7. The magnetic resonance imaging 
(MRI) from July 29, 2022, corroborates pathology at the adjacent levels of the cervical spine, in addition to the 
intervening levels. The X-rays from May 24, 2022, demonstrated a grade one anterolisthesis of C3-4 with 
evidence of dynamic instability. The enrollee has continued, persistent symptoms including ongoing subjective 
neurological complaints including bilateral hand numbness. The enrollee notes worsening of symptoms. The 
enrollee has failed conservative care measures. Additionally, the combination of spondylolisthesis, kyphosis 
and/or stenosis would render a decompression and/or more limited fusion likely to fail due to excessive 
stress/strain on such a construct. The odds would be high (that after a limited decompression alone and/or 
limited fusion) of developing more degeneration and symptoms at the remaining levels, in addition to 
instability. Therefore, the enrollee does have a diagnosis/condition that meets the criteria for the requested 
services and the requested C3-C7 laminectomy with fusion, in this case, is medically reasonable and 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 C3-C7 laminectomy with fusion have been met. Therefore, we decided that the 
Plan has to pre-approve C3-C7 laminectomy with fusion.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 8, 2022, 
through July 7, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 home health services have not been met. As per review of 
claim system, there is an NOA submitted with the "from" date as January 9, 2022, representing the continued 
care in 2022. However, the claim for the 30-day period of care, i.e., from June 8, 2022, through July 7, 2022, is 
submitted incorrectly with the admit date as January 14, 2021. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from June 8, 2022, through July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Panniculectomy (15830). 
 
You asked the Plan to pre-approve the Panniculectomy. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Panniculectomy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has undergone bariatric surgery and has lost significant 
weight. The record does not indicate that the enrollee has intertrigo unresponsive to conservative treatment or 
functional impairments. The record does not indicate the extent of the pannus. 
 
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 Panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Panniculectomy (15830).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 93313. You say that this service was reported correctly and is 
supported in the medical record. The Plan denied your request. The Plan says the payment for code 93313 is 
included in the payment for code 00567. Although 93313 was billed with a modifier for separate payment, the 
records do not support the use of this modifier 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 CPT code. In this case, we have confirmed that code 93313 
is a column II code to column I code 00567; however, 93313 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 93313. Our reviewer says that the medical 
records do not support separate billing for code 93313. Our reviewer found that the medical records provided 
do not support that CPT code 93313-59 was an independent service performed on March 31, 2022. It is 
inclusive to CPT 00567, performed on the same date; therefore, no additional reimbursement is allowed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93313 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93313 billed for date of service March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, benign lesion including margins, except skin tag 
(unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less (CPT code 11400-AS) provided 
on June 3, 2022. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says an assistant surgeon was not required for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The rules say CPT 25109, Assist Surgeon indicator is 1" which means: "(assistant-at-surgery may not be paid) 
for procedures CMS has determined that an assistant surgeon is not generally medically necessary. 
Furthermore, documentation received does not indicate that the services represented by CPT 11400 were 
performed as medical record indicates the excision performed on cyst which is 8*7cm. Per CPT code 
description of 11400, this is for the excised diameter of .5 cm or less. Therefore, we decided that the Plan does 
not have to pay for excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, 
arms or legs; excised diameter 0.5 cm or less (CPT code 11400-AS) provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on April 6, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that since the primary insurance paid, the Plan 
should pay the remainder. The Plan denied your request. The Plan says the primary insurance has not made 
payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the primary insurance has 
not made payment and there is no explanation of benefits (EOB) in the file. As the secondary insurer, the Plan 
cannot be held responsible for the outpatient services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on April 
6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The documentation does not 
support that the enrollee has either a history of osteoporosis-related fracture or that the enrollee has tried and 
failed zoledronic acid. The documentation does not support that zoledronic acid would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 (molecular pathology ctDNA test) provided 
on February 16, 2022. 
 
You asked the Plan to pay for the Guardant360 test. You say that the Guardant360 test is medically necessary. 
The Plan denied your request. The Plan says there is insufficient reliable evidence in the form of high quality 
peer-reviewed medical literature to establish the safety and efficacy or effects on health care outcomes. The test 
is experimental/investigative. 
 
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 Guardant360 test. Our reviewer says that 
the Guardant360 test is not considered medically reasonable and necessary. Our physician reviewer found that 
this test has not yet been shown in high quality studies to show its use changes overall outcomes for patients in a similar clinical scenario as this enrollee (stage IV metastatic cancer with plans for chemotherapy regardless of 
results). Therefore, without sufficient support made for clinical benefit from the use of the Guardant360 test in 
this case, it will be considered not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 test have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 test provided on February 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no imaging evidence in the 
submitted documentation showing an acute fracture that is less than six weeks old. The criteria for coverage of 
the requested kyphoplasty are not met and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.