Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for live in facility wound coverings provided on August 24, 
2022. 
 
You asked the Plan to pay for live in facility wound coverings. You say that we depend on the facility staff to 
verify eligibility and to obtain authorization. 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 live in facility wound 
coverings provided on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on August 10, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this should be covered. 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 lab services. 
 
You have been asked to pay a $40 copayment for laboratory services. This item/service falls within the lab 
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 copayment for laboratory services 
provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for STD tests provided on May 30, 2022. 
 
You asked the Plan to waive the copayment for STD tests. You say that you are disputing the share cost. 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 $50 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $50 copayment for STD tests. This item/service falls within the Outpatient 
hospital 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 copayment for STD tests provided 
on May 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on October 13, 
2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you want to appeal the amount 
being charged. 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 $35 
copayment for physician/practitoner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for telehealth visit. This item/service falls within the 
physician/practitoner services, including doctors office visits 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 telehealth visit provided on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 30, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are disabled, and on a fixed income, and cannot 
afford this. 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 September 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says inpatient level of care is not necessary, and if 
the enrollee experiences peri- or post-operative complications, reconsideration for inpatient level of care can be 
performed. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our 
reviewer says that the enrollee does not meet criteria for inpatient level of care. Our physician reviewer found 
the enrollee is in stable condition and there is not a reasonable expectation that the care would need to span at 
least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), 
amplified probe technique (U0003) provided August 4, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the COVID test was required for sailing on 
the cruise line two days prior to your departure on August 6, 2022. The Plan denied your request. The Plan says 
Per CMS guidelines COVID-19 testing for non-diagnostic testing for screening purposes is not covered by 
Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome 
Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique (U0003) 
provided August 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical shoulder arthroscopy (procedure code 29822) 
provided to the enrollee on August 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support the separate reporting of the arthroscopy of the shoulder 
with limited debridement. 
 
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 29822 is "Arthroscopy, shoulder, surgical; debridement, 
limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular 
cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, 
bursal side of the rotator cuff, subacromial bursa, foreign body[ies])." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that per the coding guidelines, shoulder arthroscopy procedures include limited debridement (e.g., CPT code 29822) even if the limited debridement is performed in a different area of the same shoulder than the other procedure. CPT 29822 is included in CPT 29824. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical shoulder arthroscopy (procedure code 29822) provided to the enrollee on August 18, 
2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gel liners, special cushion, and extra socket insert. 
 
You asked the Plan to pre-approve gel liners, special cushion, and extra socket insert. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
The Plan follows 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 gel liners, special cushion, and extra 
socket insert. Our reviewer says that the documentation does not support that the requested items are medically 
reasonable or necessary. Our physician reviewer found the enrollee has previous below the knee amputation 
and right-sided toe amputation. The enrollee has had skin ulceration due to an ill-fitting prosthesis. The 
documentation indicates the enrollee is a K2 level functional ambulator. The requested gel liners are not 
medically necessary. The special cushion and extra socket insert are included in the authorized prosthesis. 
Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gel liners, special cushion, and extra socket insert. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve gel liners, special cushion, and extra socket 
insert.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary in this case. Our physician reviewer found that you have 
chronic thoracic back pain. You are status post fusion of T4 to L1. You have had physical therapy and 
chiropractic therapy. Your medications include Tylenol, Voltaren gel, Flexeril, Gabapentin and 
hydromorphone. A computed tomography scan shows severe thoracic dextroscoliosis. There is no physical 
examination of the thorax documented. The request is for bilateral diagnostic injections T2-T3 and T3-T4 
facets. The Medicare LCD requires a physical examination be documented. At this point, the request is 
considered not 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822 and 95999 billed for date of service 
May 11, 2022. 
 
You asked the Plan to pay for procedure codes 95822 and 95999. You say that these services are supported as 
billed. The Plan denied your request. The Plan says these services are not supported in the medical record. 
 
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 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 codes 95822 and 95999. Our reviewer says that these services are not supported in the medical record. Our reviewer found the record shows that code 95822 
was reported for neuromonitoring during anesthesia; however, there is a more specific code to use for the 
services performed in this case. In addition, the record shows that 95999 was used to report train of four 
testing. According to Medicare billing rules, train of four is included in intraoperative neuromonitoring and is 
not reported separately. Therefore, these codes are not supported. 
 
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 codes 95822 and 95999 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95822 and 95999 billed for date of service May 11, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
February 10, 2022. 
 
You asked the Plan to pay for hospital discharge management. You say that this service is supported in the 
medical record. The Plan denied your request. The Plan says the medical records provided do not support the 
reported service. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the medical record. Without this information, a time-based code such as 99239 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of hospital discharge 
management have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. 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 a FDG PET scan is covered under certain conditions. 
 
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 PET scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case as the enrollee is 
not noted to have met criteria for a diagnosis of both AD and FTD (rather the evaluation only points towards AD at this time), the base requirement for this testing would not be met/satisfied. In as much this service would 
not meet the NCD criteria for coverage. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Positron Emission Tomography (PET) scan of the brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a core build-up 
(D2950) provided on August 4, 2022. 
 
You asked the Plan to pay for a limited oral evaluation and a core build-up. You say that this was an 
emergency. The Plan denied your request. The Plan says the denied services are not covered 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 a limited 
oral evaluation (D0140) and a core build-up (D2950) provided on August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a humidification device for a ventilator. 
 
You asked the Plan to pre-approve a humidification device for a ventilator. You say that the enrollee cannot 
really breathe on their own and the requested equipment is medically necessary. The Plan denied your request. 
The Plan says that the records do not show a written order supportive medical documentation, or correct coding 
for the device which remains in dispute. 
 
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 a humidification device for a ventilator. 
Our reviewer says that a humidification device for a ventilator is considered medically reasonable and 
necessary in this case. Our physician reviewer found a humidifier for the home ventilator is reasonable and 
medically necessary.  This patient has chronic obstructive pulmonary disease (COPD) and restrictive lung 
disease from sarcoidosis, with mild chronic carbon dioxide (CO2) retention. A home ventilator has been 
approved. A humidification device is medically necessary when using the ventilator to prevent drying of the 
airways and mucous plugging. 
 
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 humidification device for a ventilator have been met. Therefore, we decided 
that the Plan has to pre-approve a humidification device for a ventilator.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for IRF care for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was 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 notes that at the time of the appeal, there was not an expectation that the enrollee could participate in intensive rehabilitation therapy for at least three hours of per day at least five days per week due to hip fracture.
The Plan is correct in this case. 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. While IRF care may have been considered beneficial, the enrollee did not meet the criteria required for admission at the time of the appeal.
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee during an inpatient stay on April 9, 2022.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says inpatient services are covered under the facility inpatient claim. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim should be submitted to the facility and not the Plan.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary during inpatient care.
The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee during an inpatient stay on April 9, 2022.