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

 
We decided that the Plan does not have to pre-approve Methocarbamol. 
 
You asked the Plan to pre-approve Methocarbamol. You say that you would like to continue the low dose 
Robaxin at this time for pain and function. You also say that the enrollee has tolerated this in the recent past 
and you are not comfortable switching to Flexeril or Tizanidine with higher side effect risk of drowsiness 
which increases the enrollee's fall risk. The Plan denied your request. The Plan says Methocarbamol is a self-
administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methocarbamol.  
 
 Benefits for Methocarbamol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ventolin. 
 
You asked the Plan to pre-approve Ventolin. The Plan denied your request. The Plan says Medicare guidance 
says non-injectable, self-administered drugs, like Ventolin, are covered by the pharmacy (drug) benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ventolin.  
 
Benefits for Ventolin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from September 29, 2021, 
to September 30, 2021. 
 
You asked the Plan to pay for the inpatient admission. You say that this admission was medically necessary. 
The Plan denied your request. The Plan says the care delivered was consistent with an observation stay. The 
Plan also says that there was no medical necessity for formal hospitalization. 
 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 pay for the inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found although it was reasonable to monitor the patient on telemetry while being treated, it 
was not expected that correction of the hyperkalemia would likely cross 2 midnights in the hospital, as the 
patient was stable. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from September 29, 2021, to September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic manipulative treatment and 
does not have to pay for therapeutic activities provided on November 8, 2021. 
 
You asked the Plan to waive the copayment for chiropractic manipulative treatment and to pay for therapeutic 
activities. The Plan denied your request. The Plan says the claim processed 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 8%  
for Chiropractic Services, out-of-network.  
 
You have been asked to pay 8% for chiropractic manipulative treatment. The chiropractic manipulative 
treatment falls within the Chiropractic 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 chiropractic manipulative treatment provided on November 8, 2021. Additionally, the records 
show that therapeutic activities at issue is not manual manipulation of the spine. Therefore, we decided that the 
Plan does not have to pay for therapeutic activities provided on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
May 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on July 14, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the services were performed and billed by a valid, 
participating provider. You also say that all services rendered were properly ordered and signed by the referring 
physician and deemed medically necessary for this patient per diagnosis of treatment. The Plan denied your 
request. The Plan says the services are not authorized because the non-network provider who does not work 
with the member's Plan, and the member was referred by a provider who also does not work with the Plan.  The Plan also says that the member's primary care physician did not refer for services, and there is no network 
deficiency for these services and alternate network providers were found. 
 
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 drug testing (80307, G0483) provided on July 14, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive hereditary cardiovascular panel (81401, 
81403, 81404, 81405, 81406, 81408, 81407) provided on September 15, 2021. 
 You asked the Plan to pay for a comprehensive hereditary cardiovascular panel. You say that this is supported 
in the records. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive hereditary 
cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive hereditary cardiovascular panel (81401, 81403, 81404, 81405, 81406, 81408, 81407) provided 
on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on April 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says prior authorization is required for an out-of-network office visit. 
 
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 Genetic Testing provided on April 19, 2021 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from October 14, 2020, to October 
23, 2020, as billed with Diagnosis Related Group (DRG) 854. 
 
You asked the Plan to pay for inpatient care billed with DRG 854. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 854 is not supported as the diagnosis of sepsis, unspecified organism (A41.9) is not 
supported in the medical record. The Plan argues that DRG 617 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 854. Our 
reviewer says that the medical records do not support the billing of diagnosis sepsis, unspecified organism 
(A41.9). Our physician reviewer found that the enrollee was admitted for further evaluation and treatment of 
chronic osteomyelitis. The consult noted that the enrollee was undergoing a septic workup. A necrotic area to 
the back of the heel and foot was noted. Discharge summary noted the enrollee had sepsis as well as other 
conditions. However, while sepsis is noted, supporting medical record documentation was not found within the 
record. The review has determined that the medical records did not support the billing of sepsis, unspecified 
organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 854 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient care provided from October 14, 2020, to October 23, 2020, as 
billed with Diagnosis Related Group (DRG) 854.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for aflibercept injections provided from 
September 7, 2021, to October 5, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you cannot afford the increase in 
coinsurance for the new drug. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for Part B drugs. 
 
 
 
 Drug Allowed Amount 20% Coinsurance 
Aflibercept - September 7, 2021 $1,832.82 $366.56 
Aflibercept  October 5, 2021 $1,835.89 $367.18 
Total:  $733.74 
 
You have been asked to pay $733.74, which is 20% of the allowed amount for the injections. The injections fall 
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 
coinsurance for aflibercept injections provided from September 7, 2021, to October 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from March 3, 2021, 
to June 29, 2021. 
 
You asked the Plan to pay for the home health care services. The Plan denied your request. The Plan says the 
initial Request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of 
care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, March 3, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health care services provided from March 3, 2021, to June 29, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for cardiovascular testing provided on November 15, 
2021. 
 
You asked the Plan to waive the coinsurance for cardiovascular testing. You say that your doctor prescribed 
medication that led to you needing these services. You feel that the doctor should be liable for these services. 
The Plan denied your request. The Plan says that the coinsurance applied was correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the Schedule of Cost Sharing. Therefore, we 
decided that the Plan has to waive the coinsurance for cardiovascular testing provided on November 15, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on April 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the test assists in the treatment decisions for 
the enrollee's disorder. The Plan denied your request. The Plan says the procedure codes billed are not correct. 
 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 looked at the file and the rules. We find that the gene panel at issue was billed with multiple codes. If a 
single procedure is performed, only one code with one unit of service may be reported for the procedure.  
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the Tempus gene panel provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency anesthesia rendered on November 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99140 (emergency anesthesia services) has a 
status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to 
pay for the emergency anesthesia rendered on November 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve Emgality. You say that the enrollee has had the loading dose of Emgality 
(samples) and has only had 2 migraines since, which is a huge improvement. You also say that is important that 
the enrollee continues with Emgality as it is already providing relief. The Plan denied your request. The Plan 
says Emgality is a self-administered drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality.   
Benefits for Emgality may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on July 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on October 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
TOB code 032x. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered on October 29, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 64447 and 01402. We decided that the Plan does not 
have to pay for procedure code 99100.  
 
You asked the Plan to pay for the services at issue. The Plan denied your request. The Plan says that no 
separate payment is made. 
 
We decided that the Plan has to pay for procedure codes 64447 and 01402.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The case file shows that codes 64447 and 01402 were denied as a duplicate. There is no documentation to show 
that these services were previously billed and paid for by the Plan. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request. 
Therefore, we decided that the Plan has to pay for procedure codes 64447 and 01402.  
 
We also decided that the Plan does not have to pay for procedure code 99100. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. We find that CPT code 99100 is a bundled code. When these services are 
covered, payment for them is subsumed by the payment for the services to which they are incident. Therefore, 
we decided that the Plan does not have to pay for procedure code 99100. 
 
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.