Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy services the enrollee.
You asked the Plan to pre-approve these services. You say that the device is medically necessary to monitor the enrollee's lymphedema. The Plan denied your request. The Plan says that the procedure is unproven and not medically necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical director looked at the case file and the reopen request. At issue is coverage for bioimpedance spectroscopy services. Our Medical director says that the evidence in the medical literature and the clinical documentation in this case are insufficient to support that bioimpedance spectroscopy is medically reasonable and necessary for this enrollee. Our Medical director found that the enrollee's condition does not meet criteria for coverage of these services.
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 bioimpedance spectroscopy services the enrollee.
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 enrollee is suitable for transfer to 
LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 appears to still be somewhat unstable but is improving with current 
treatment and requires additional acute care services that can be safely provided at the current facility until 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires which are 
not available at the current 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve a CT of the chest. The Plan denied your request. The Plan says 
documentation has not been submitted that would substantiate this diagnosis or support the need for a chest CT 
scan. 
 
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 pre-approve a CT of the chest. Our reviewer says 
that a CT of the chest is not reasonable and necessary. Our physician reviewer found you have a history of a 
nonspecific heart murmur. There is mention of slight prominence of the ascending thoracic aorta and a CT of 
the chest has been requested for evaluation.  There is concern about the non-specified heart murmur. Our 
reviewer found you had a negative 2 view chest x-ray on September 28, 2022. Our physician reviewer also 
found that there is no documentation in the submitted records of how the mild prominence of the ascending 
thoracic aorta has been documented in the past, so it is impossible to establish the need for this test via the 
submitted records. 
 
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 CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for any of the requested components.
You asked the Plan to provide coverage for this equipment. You say that these power wheelchair components are medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. The power seat elevation system (E2300) is not covered by Medicare. At issue is coverage for an expandable controller (E2377), harness (E2313), and electronic connection between wheelchair controller and two or more power seating system motors (E2311). The Maximus Physician Reviewer determined that the requested items to be medically reasonable and necessary. The Plan requested a reopen and argues Maximus did not apply the correct coverage criteria. The medical records who you are a 53-year-old man with a history of spinal cord injury (C5-C7 incomplete), causing tetra-paresis. The Plan is correct in this case. The clinical documentation does not support that the requested components are medically necessary or that you meet the required coverage criteria to allow approval. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to provide coverage for a power seat elevation system (E2300), expandable controller (E2377), harness (E2313), and electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested 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 a total hip arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable 
and comprehensive, less invasive conservative-care measures. There is no documentation of a trial and failure 
of therapy and/or injections. There are limited large-scale, long-term references showing the safety and efficacy 
of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty (27130).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurances for the injections provided on July 16, 2021. 
 
You asked the Plan to waive the coinsurances for the injections. You say that you thought the cost for these 
services would be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly 
and the enrollee did not hit their yearly maximum out-of-pocket amount prior to the date of service. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $4,900 
in-network maximum out-of-pocket amount before you have no out-of-pocket costs for the rest of the year. 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for chemotherapy drugs.  
 
Prior to the date of service, the total amount paid towards the MOOP was $4,124.73 leaving $775.27 to pay 
towards the $4,900 MOOP. The first total amount allowed was $2.04 with a coinsurance charge of $0.41 
($2.01 total amount x 20% coinsurance). The second total amount allowed was $0.95 with a coinsurance 
charge of $0.19 ($0.95 total amount x 20% coinsurance). The third amount allowed was $594.20 with a 
coinsurance charge of $118.84 ($594.20 total amount x 20% coinsurance). The fourth amount allowed was 
$2,469.36 with a coinsurance charge of $493.87 ($2,469.36 total amount x 20% coinsurance). The fifth amount 
allowed was $9.92 with a coinsurance charge of $1.98 ($9.92 total amount x 20% coinsurance). The sixth 
amount allowed was $30.55 with a coinsurance charge of $6.11 ($30.55 total amount x 20% coinsurance). The 
seventh amount allowed was $10,270 with a coinsurance amount of $153.87; since the enrollee hit their MOOP 
amount for the year the coinsurance amount charged was less than 20%. 
 
You have been asked to pay a $775.27 coinsurance for the injections. This item/service falls within the 
Medicare part B prescription drugs 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 coinsurances for 
the injections provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing (81479) provided on December 5, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 81479 is "Unlisted molecular pathology procedure". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the testing. Our reviewer says that the use of code 81479 is 
not supported by the records provided. Our reviewer found that the laboratory report does not support an 
unlisted pathology procedure. A laboratory report was not found to support the procedure has been performed, 
nor if it was reported correctly. The medical record includes a physician order and evaluation and management 
service, however no lab report was found. Therefore, correct billing and reporting cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the testing (81479) provided on December 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to provide coverage for V-Beam (laser) treatment for Rosacea.
You asked the Plan to provide coverage for V-Beam (laser) treatment. You say that this treatment is medically
necessary. The Plan denied your request. The Plan says Medicare does not cover this treatment for Rosacea.
Maximus overturned the procedure as medically beneficial. The Plan requested a reopen and stated that the
issue was not medical necessity but the fact that it is not covered by Medicare for treatment of Rosacea.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules specifically state V-Beam
treatment is not covered for Rosacea. The medical records specifically state the assessment of your condition is
Rosacea. While this treatment may be beneficial for you, it is not covered by Medicare for your condition.
Therefore, we decided that the Plan does not have to provide coverage for V-Beam (laser) treatment for
diagnosis of Rosacea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist/physician
other than the ordering dentist/physician (D9310) provided on October 19, 2021.
You asked the Plan to pay for the diagnostic consultation. You say that you had an appointment with one oral
surgeon but were then seen by another provider and informed that the one you believed you were going to see
was at a different location. The Plan denied your request. The Plan says that this service is not covered by your
dental benefit.
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.
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 diagnostic consultation provided by a
dentist/physician other than the ordering dentist/physician (D9310) provided on October 19, 2021.
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 these services are medically necessary. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
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's current needs can be provided at the current 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more toward the office visit (99214), visual field exam (92083) 
and ophthalmic imaging (92134) provided on June 15, 2022.  You asked the Plan to pay more toward the office visit (99214), visual field exam (92083) and ophthalmic 
imaging (92134). You say that you have macular degeneration, and the doctor requested the scan to evaluate 
any changes in the retina. The Plan denied your request. The Plan says the $45 copayment applied correctly to 
the office visit (99214) and visual field exam (92083). The Plan also says the ophthalmic imaging (92134) is 
included in another service provided during the same visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that for edits with a modifier indicator of 0, the 
Column 2 code cannot be paid regardless of whether a modifier is used. 
 
You have been asked to pay a $45 copayment for the office visit (99214) and visual field exam (92083). These 
services fall within the Physician/Practitioner services, including doctor's office visits benefit category. In 
addition, we have confirmed that code 92134 is a column II code to column I code 92133 with a modifier 
indicator of 0. The column II code is therefore not payable. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay 
more toward the office visit (99214), visual field exam (92083) and ophthalmic imaging (92134) provided on 
June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator to be used for the treatment of 
COPD. The Plan denied your request. The Plan says the request for continued coverage of a home mechanical 
ventilator that is not being used by the member is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have COPD and obesity-
hypoventilation syndrome and have had a Trilogy ventilator since 2018. The device download covering March 
through September 2022 shows very little usage, only 4.3% of days with usage at least 4 hours. This is not 
enough to be effective and does not meet Medicare minimum criteria of at least 70% of days with at least 4 
hrs/day. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood glucose test or reagent strips for home blood glucose 
monitor, per 50 strips (A4253) lancets, per box of 100 (A4259) normal, low, and high calibrator solution/chips 
(A4256) home blood glucose monitor (E0607) spring-powered device for lancet, each (A4258) replacement 
lithium battery (A4235) provided June 21, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that the supplies were prescribed by the physician 
as a medical necessity for the monitoring and treatment of diabetes. The Plan denied your request. The Plan 
says the plan denied services are not documented in the enrollee's medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The medical records included with the appeal do not include medical 
exam notes and there are no claims in the enrollees claims history from the prescribing provider on the date of 
service, or in the last 6 months prior to the date of service. Based on this information, we decided that Medicare 
rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have 
to pay for blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (A4253) lancets, 
per box of 100 (A4259) normal, low, and high calibrator solution/chips (A4256) home blood glucose monitor 
(E0607) spring-powered device for lancet, each (A4258) replacement lithium battery (A4235) provided June 
21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (36217, 36218) provided on November 24, 
2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 36217, & 36218 are not supported in the medical record. Specifically, the 
documentation does not include selective catheter placement, third order or more, and therefore cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the surgical services have 
not been met. Therefore, we decided that the Plan does not have to pay for surgical services (36217, 36218) 
provided on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that a Dexcom G6 transmitter is 
medically necessary. The Plan denied your request. The Plan says they were unable to get information about 
the enrollee's condition, which is required according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. We found that there were no medical records or documents submitted 
to show that the requested device is medically necessary, despite reasonable attempts made by the Plan to 
obtain this necessary documentation. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Dexcom G6 transmitter have been 
met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 transmitter.