Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377, E2313, E2311). We decided 
that the Plan does not have to pre-approve a power seat elevation system (E2300) and a cup holder (K0108).  
 
You asked the Plan to pre-approve an expandable controller (E2377, E2313, E2311), a power seat elevation 
system (E2300), and a cup holder (K0108).. You say that these items are medically necessary. The Plan says 
that the enrollee can operate the approved power options through their own switches and the other items are not 
medical in nature. 
 
We decided that the Plan has to pre-approve an expandable controller (E2377, E2313, E2311).  
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is 
medically necessary for any of the functions listed in the 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 an expandable controller (E2377, 
E2313, E2311). Our reviewer says that the requested expandable controller is medically necessary. Our 
physician reviewer found the enrollee has multiple approved power drives and very limited hands hand 
strength, requiring an expandable controller to allow a single point of control.  
 
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, E2313, E2311) have been met. Therefore, we 
decided that the Plan has to pre-approve an expandable controller (E2377, E2313, E2311).  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and a 
cup holder (K0108). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  A power seat elevation feature (E2300) and power standing feature (E2301) are non- covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested power seat elevation system (E2300) and cup holder 
(K0108) are not medical in nature. Based on this information, we decided that Medicare rules for coverage of a 
power seat elevation system (E2300) and a cup holder (K0108) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation system (E2300) and a cup holder (K0108). 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary under certain circumstances. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence 
provided that would support the need for repeat radionuclide stress testing at this time. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing 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 myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on March 21, 2022.
You asked the Plan to pay for this claim as billed. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the claim was not submitted with an appropriate provider taxonomy code. Maximus overturned the Plans denial for insufficient information in the case tile. The Plan requested a reopen and provided additional information.
The Plan notes that It has been determined that claim - Psychiatric diagnostic evaluation with medical services denied because this provider was not certified/eligible to be paid for this procedure/service on this date of service. According to our review, the provider is loaded under the NPPES NPI Registry as Nurse Practitioner Psych/Mental Health but the appealed claim was billed with the other taxonomy. The case file includes the appealed claim that shows the provider has billed with Registered Nurse taxonomy code as their primary specialty. Based on this information, we decided that Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-sharing for the bone imaging (78306) provided on March 23, 2022.
You asked the Plan to reduce the cost-sharing for the bone imaging. You say that you were informed of only a $180 copayment at the time of service. 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 $325 copayment for Nuclear Medicine Services. You have been asked to pay a $233.17 copayment for the bone imaging. This item/service falls within the Nuclear Medicine Services benefit category. This means that you have been asked to pay less than the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost-sharing for the bone imaging (78306) provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99214) provided on August 29, 2022. 
 
You asked the Plan to pay for a specialist office visit (99214). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a specialist office visit 
(99214) provided on August 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab, Ipilimumab, and Bevacizumab for the enrollee.
You asked the Plan to pre-approve Nivolumab, Ipilimumab, and Bevacizumab. You say that this is medically necessary. The Plan denied your request. The Plan says that there is a lack of indication for using these drugs.
Our Medical director looked at the case file and the reopen request. At issues is coverage for Nivolumab, Ipilimumab, and Bevacizumab. Our Medical Director states that there is insufficient support in the compendia and in the medical literature for the use of Nivolumab, Ipilimumab, and Bevacizumab in the management of recurrent rectal adenocarcinoma with metastases. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Nivolumab, Ipilimumab, and Bevacizumab.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nivolumab, Ipilimumab, and Bevacizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Nivolumab, Ipilimumab, and Bevacizumab for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) provided to the enrollee on January 21, 2022.
You asked the Plan to pay for the testing. You say that the F1Heme test is a proven medically necessary covered benefit for comprehensive genomic profile testing for cancer to identify potential targeted therapy options. The Plan denied your request. The Plan says that this was not taken by the laboratory directly.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) provided to the enrollee on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystic fibrosis screen (81220) and spinal muscular 
atrophy (SMA) carrier screening in pregnancy (81329) provided September 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the treating physician made a professional 
determination of diagnosis and concluded the testing was medically necessary in order to successfully treat the 
enrollee. The Plan denied your request. The Plan says this code is considered a screening test that is statutorily 
excluded. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the codes in question is considered a screening test that is statutorily excluded per 
Medicare Claims Processing Manual Chapter 16 - Laboratory Services Section-120.1: "Tests that are 
performed in the absence of signs, symptoms, complaints, personal history of disease, or injury are not covered 
except when there is a statutory provision that explicitly covers tests for screening as described. There was no 
specific clinical rationale provided for the requested test. The review has determined that the items/services at 
issue in this case medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the cystic fibrosis screen (81220) and spinal muscular atrophy (SMA) carrier screening 
in pregnancy (81329) provided September 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services, hip 
surgery, and observation care provided from September 27, 2022, to September 28, 2022. 
 
You asked the Plan to waive the copayments for the PT services, hip surgery, and observation care. You say 
that you cannot afford the cost of the services. 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 $40 
copayment for speech and physical therapy services, a $325 copayment for outpatient hospital services, and a 
$35 copayment for physician specialist services.  You have been asked to pay a $40 copayment for the PT services. This item/service falls within the speech and 
physical therapy services benefit category. You have also been asked to pay $90.99 for the hip surgery, which 
is less than the $325 standard copayment. This item/service falls within the outpatient hospital services benefit 
category. You have also been asked to pay a $35 copayment for the observation care. This item/service falls 
within the physician specialist services 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 copayments 
for physical therapy (PT) services, hip surgery, and observation care provided from September 27, 2022, to 
September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nail(s) provided on September 02, 2022. 
 
You asked the Plan to pay for debridement of nail(s). You say that due to incorrect Plan information, you were 
unable to obtain prior authorization for the services. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement of nail(s) 
provided on September 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay from August 19, 
2022, to August 22, 2022. 
 
You asked the Plan to reduce the copayment for inpatient hospital stay. You say that for your inpatient stay 
from August 19, 2022, to August 22, 2022, you are being billed for an intensive care unit (ICU) stay; however, 
you were in a regulatory hospital room. 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 for each Medicare-
covered stay in a network hospital, enrollees must pay $315 per day for days 1 to 5 and $0 per day for days 6 
and over.   
 
You have been asked to pay $945 for the inpatient hospital stay ($315/day x 3 days = $945). The inpatient 
hospital stay falls within the inpatient hospital care benefit category. It does not matter what type of room you 
are in while an inpatient, the copayment remains the same. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment 
for inpatient hospital services provided from August 19, 2022, to August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental cleaning and scaling services (D4346) provided on 
May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 dental 
cleaning and scaling services (D4346) provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on August 08, 2022. 
 
You asked the Plan to pay for a walker. You say that you would like this item to reimbursed. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a walker provided on 
August 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 1, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81479, 81407 
and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 1, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 
0032U, 0033U, 81479, 81407 and 81238.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental crowns (D2751, D2752) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and were told these services would be covered. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental crowns (D2751, D2752) provided on March 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic image of the image and the chest provided on 
March 29, 2022. 
 
You asked the Plan to pay for a diagnostic image of the image and the chest. You say that the service billed 
was not more than the allowed amount per the provider contract. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a diagnostic image of the image and the chest provided on 
March 29, 2022.