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

 
We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services provided 
on November 11, 2022, through November 14, 2022. 
 You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that the cost share is 
wrong. 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 20% 
coinsurance for outpatient hospital services.  
 
You have been asked to pay a 20% coinsurance for the outpatient hospital services. 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. Your out-of-pocket maximum was met partway through the claim, so you do 
not have to pay the full 20%. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the outpatient hospital services provided on November 11, 2022, through November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1830) provided on October 18, 2022. 
 
You asked the Plan to pay for the services. You say that prior authorization was not able to be obtained before 
the durable medical equipment (DME) was ordered. The Plan denied your request. The Plan says the records 
do not show that there was knee injury or surgery. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation provided does not support the need for a knee orthosis. The patient has a 
medical history of requiring hip arthroplasty due to osteoarthritis. She has generalized ligamentous laxity that 
predisposed her to experiencing a hip dislocation after her arthroplasty. This required reduction on 10 18 2022. 
The patient is noted to have ligamentous laxity and a history of hip dislocation, but there is insufficient 
documentation indicating that the patient has instability or recent injury or surgery of the knee joint. She has undergone knee arthroplasty in the past, but this was not recent and was performed on 2/18/2020. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1830) provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dermatology visit provided on 
September 15, 2022, and October 27, 2022. 
 
You asked the Plan to waive the copayment for the dermatology visits. You say that you think that you were 
billed incorrectly for these 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 $35 
copayment for each in-person specialist visit. 
 
You have been asked to pay a $70 copayment for the dermatology visits ($35 x 2 visits = $70). These 
items/services fall within the physician/practitioner services, including doctor's 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 the dermatology visit provided on September 15, 2022, and 
October 27, 2022.  Your complaint about the length of the dermatology visits is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from March 9, 2022, to 
March 11, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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.   
 
In this case, you billed the inpatient services provided with DRG 872. 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 hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the only sepsis criteria present in this enrollee's record is low platelets but low platelets can also be seen 
with a viral illness absent sepsis. No other criterion for sepsis was present.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from March 9, 2022, to March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses and anti-reflective coating provided on 
November 1, 2022. 
 
You asked the Plan to pay for the progressive lenses and anti-reflective coating. You say that you have not used 
the Plan to purchase eyewear and you are entitled to receive payment. The Plan denied your request. The Plan 
says there is only a $130 combined allowance for eyeglasses and contact lenses every 12 months.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan will only pay $130 every year for covered eyewear. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the progressive lenses and anti-reflective coating have not been met. Specifically, the Plan has paid 
$130 toward the purchase of the frames on November 1, 2022, which exhausted your benefit. Therefore, we 
decided that the Plan does not have to pay for the progressive lenses and anti-reflective coating provided on 
November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel rendered on September 6, 2022.  
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted documentation contains 
only a pathology report showing right lung adenoid cystic carcinoma and the test results. There is no 
documentation supporting that the test results would directly impact treatment or management of the enrollee. 
There is no documentation supporting that the number of genes tested was reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus gene panel rendered on September 6, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for radiological services provided on September 12, 2022, billed with code 
76882. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the code was billed with an 
incomplete/invalid modifier. 
 
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. We find that the specific denial rationale offered by the Plan is not supported. 
While the line item for the right-sided imaging does include a pointer that identifies the left-sided knee pain, it 
also does point to the correct diagnosis for right-sided knee, as is also done with the left-sided line item. The 
Plan has not provided a rule that specifically supports denial of a claim simply due to a line item being 
associated with an inapplicable diagnosis as well as the correct diagnosis. Both conditions on the claim are 
documented in the record as are the two sides being imaged. The Plan has not provided any alternate rationale. 
As such, we find that the denial of payment on this basis is not substantiated. Therefore, we decided that the 
Plan has to pay for radiological services provided on September 12, 2022, billed with code 76882.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper extremity prosthesis (L7499). 
 
You asked the Plan to pre-approve an upper extremity prosthesis. You say that you disagree with the denial. 
The Plan denied your request. The Plan says approval is subject to correct coding by the prosthetic provider. 
 
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 code L7499 is not supported in the medical record. Specifically, body-powered partial hand 
prostheses are correctly coded when the amputation matches one of the partial hand prosthetic body-powered 
codes (L6000, L6010, L6020). Code L7499 must not be used to bill for any features or functions included in 
the base L-code, nor should it be used when a specific L-code exists. A prosthesis that meets the enrollee's 
needs and Medicare guidelines can be reviewed if submitted. Based on this information, we decided that 
Medicare rules for coverage of an upper extremity prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an upper extremity prosthesis (L7499).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on September 22, 
2021, to September 23, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this inpatient stay has been correctly denied. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two 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 pay for the acute inpatient hospital care provided on September 22, 2021, to September 
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on June 9, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99285 is an Emergency Department visit, requiring a 
comprehensive history, a comprehensive examination and medical decision making of high complexity. 
 
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 emergency room services. Our reviewer says that the 
billed code is not supported by the records. Our reviewer found the documentation available for review does 
not support that the presenting problems were of high severity or that the medical decision was of high 
complexity. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided June 16, 2022, to June 18, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that this inpatient admission has been correctly denied. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided June 16, 2022, to June 18, 2022.  
 
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 xF liquid biopsy rendered on February 14, 2022. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that genomic sequence panels are covered when 
specific criteria are met.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found that the provided records only include the 
Tempus requisition form and the test results. The records do not indicate that the enrollee is a candidate for 
intensive chemotherapy with an anti-EGFR biologic agent; and has not had prior RAS/BRAF testing (except 
after initiation of anti-EGFR therapy with evidence of acquired resistance, as required by the Medicare criteria. 
The records do not support that the services were reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus xF liquid biopsy rendered on February 14, 2022.  
 
Local Coverage Determination (LCD) L35025 referenced by the Plan does not provide binding coverage 
criteria and was not used in the MAXIMUS determination.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from January 16, 2022, 
to January 22, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there was no new documentation or clinical 
evidence presented to support an overturn of the initial audit findings. 
 
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.   
 
In this case, you billed the inpatient services provided with DRG 189. 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 hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that due to the provided documentation not sufficiently supporting the diagnosis of acute respiratory failure due 
to not requiring high flow oxygen, bilateral positive airway pressure (BiPAP), or vent support, the code for 
such cannot be validated or justified, and therefore, the DRG J44.1 would be more appropriate for this hospital 
stay.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from January 16, 2022, to January 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel (81225, 81226, 
81227, 81231, 81238, 81240, 81241, 81291, 81306, 81335, 81355, 81401) provided on July 26, 2022. 
 
You asked the Plan to pay for the comprehensive pharmacogenetics panel. You say that this testing should be 
covered. The Plan denied your request. The Plan says the testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The test panel is a single test with multiple components. A panel 
cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple 
individual pathogens and/or targets. Based on this information, we decided that Medicare rules for coverage of 
the comprehensive pharmacogenetics panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the comprehensive pharmacogenetics panel (81225, 81226, 81227, 81231, 81238, 81240, 
81241, 81291, 81306, 81335, 81355, 81401) provided on July 26, 2022.