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

 
We decided that the Plan does not have to pay for the Wide Area Transepithelial Sampling with 3-Dimensional 
Analysis (WATS 3D) test provided to the enrollee on February 5, 2021. 
 
You asked the Plan to pay for the services. You say that this is now a standard of care. The Plan denied your 
request. The Plan says the medical literature and clinical practice guidelines do not support the clinical utility 
of testing with computer-assisted immunohistochemistry to predict cancer. 
 
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 the 2011 guidelines on diagnosing Barrett?s or dysplasia does not address WATS-3D, but states that 
endoscopy has become standard practice for diagnosis; no updates have been issued by the College since then. In September 2019, the American Society for Gastrointestinal Endoscopy?s Standards of Practice Committee 
issued a guideline on screening and surveillance of Barrett?s esophagus. The panel initially made no 
recommendation for WATS-3D at the face-to-face meeting. 
 
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 the Wide Area Transepithelial Sampling with 3-Dimensional Analysis (WATS 3D) test 
provided to the enrollee on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2392) and one surgical 
extraction (D7210) or pay in full for the additional surgical extraction (D7210) provided on July 14, 2021. 
 
You asked the Plan to pay for the resin-based composite and one surgical extraction and to pay in full for the 
additional surgical extraction. You say that you only went to the dentist once and did not know the Plan only 
covered $1,000 worth of services. You also say that the dentist should have advised you ahead of time. The 
Plan denied your request. The Plan says the calendar year maximum allowance has been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
you are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for the July 14, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2392) and one surgical extraction (D7210) or pay in full for the additional surgical 
extraction (D7210) provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 10, 
2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare covers lipid panel testing as cardiovascular screening once every 5 years. 
 
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 Medicare denies coverage for all cardiovascular genetic risk assessment panels. Medicare only covers a 
lipid panel consisting of a total cholesterol, HDL cholesterol, and triglyceride once every 5 years as 
cardiovascular screening. The review has determined that the services at issue in this case are not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedic 
surgeon on April 4, 2019. 
 
You asked the Plan to waive the copayment for the orthopedic visit. You say that you do not believe these 
services took place. The Plan denied your request. The Plan says you were charged this copayment 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 visits with a specialist.  
 
 The medical records confirm that you were seen by the orthopedist on this date. The records show that you 
were sent for right knee pain related to your original Worker's compensation injury you sustained in 2012. The 
records state that your knee had become symptomatic again, giving you pain when walking, standing, bending, 
or climbing stairs. You have been asked to pay a $50 copayment for the orthopedic visit. The orthopedic visit 
falls within the visits with a specialist 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 office visit you had with an orthopedic surgeon on April 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services provided on May 14, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are not payable. 
 
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, the CPT Code Manual definition of code 29876 is arthroscopy, knee, surgical; synovectomy, 
major, 2 or more compartments (e.g., medial or lateral). We find that CPT code 29876 is not supported in the 
medical record. CPT code 29876 may be reported for a medically reasonable and necessary synovectomy with 
another arthroscopic knee procedure on the ipsilateral knee if the synovectomy is performed in 2 compartments 
on which another arthroscopic procedure is not performed.  
 
The CPT Code Manual definition of code 29877 is Arthroscopy, knee, surgical; debridement/shaving of 
articular cartilage (chondroplasty). When billed with code 29876, CPT code 29877 is not eligible for payment. 
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on May 14, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two pontics (D6245 x2) and two retainer crowns (D6740 
x2) provided on June 22, 2021. 
 
You asked the Plan to pay for the pontics and retainer crowns. You say that the agent who sold you on this plan 
advised that dental work would be covered at 100%. You also say that the dental office contacted the Plan for 
approval for the dental work and were also advised that it would be covered at 100% The Plan denied your 
request. The Plan says these services are not covered. The Plan says that you did not contact the Plan prior to 
this date of service to verify benefits and provider eligibility 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
pontics (D6245 x2) and two retainer crowns (D6740 x2) provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the medical records show that the enrollee meets 
the Medicare rules for the non-invasive home ventilator that is being requested. The Plan denied your request. 
The Plan says the records do not show that the enrollee meets the Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe chronic obstructive pulmonary disease. Overnight capnography 
suggests brief episodes of carbon dioxide retention during sleep. 
  
 However, Medicare requires confirmation of elevated partial pressure of carbon dioxide on an arterial blood 
gas while the enrollee is stable and awake for coverage of bilevel positive airway pressure (BiPAP). Medicare 
does not cover a home ventilator when used as BiPAP. A home ventilator is not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
May 25, 2021. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 diagnostic tests provided in an outpatient hospital facility. 
 
The record shows that you received an outpatient diagnostic test on May 25, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $50 copayment.   
 
You have been asked to pay a $50 copayment for an outpatient diagnostic test. An outpatient diagnostic test 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an outpatient diagnostic test provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on March 15, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare 
denies coverage for all cardiovascular risk assessment panels for suspected or documented cardiovascular 
disease. 
 
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. 
 
We looked at the file and the rules. The medical records do not show that the results of testing will impact 
clinical management in a manner already demonstrated in the peer-reviewed published literature to improve 
patient outcomes. The test at issue in this appeal was requested for screening purposes. Medicare does not 
cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the testing 
services provided on March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsurgery add-on services represented by code 69990 and 
billed for date of service March 24, 2021. 
 
You asked the Plan to pay for the microsurgery add-on services. You say that the medical records provided 
support the code in dispute. The Plan denied your request. The Plan says payment for the services represented 
by the code 69990 is included in the payment that was already made on code 63047. 
 
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, we have confirmed that code 69990 
is a column II code to column I code 63047. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for microsurgery add-on services represented by code 69990 and 
billed for date of service March 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says your records do not show you do not require skilled nursing services or skilled 
rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF. The 
Plan states your rehabilitation and medical needs can be met with part-time skilled services in a lower level of 
care, such as home with supervision and home health services. The Plan states home health services will need 
to be approved by your health plan. The Plan states your rehabilitation needs can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with 
your doctor. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that you require 
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are 
not required to safely and effectively provide medically necessary and reasonable treatment. You do require 
skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required 
to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not 
required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in the home with home health care or in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical services provided by an 
in-network hospital on June 29, 2021. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you were told by a Plan 
representative that you would not be responsible for any facility fees. The Plan denied your request. The Plan 
says the cost-share was applied correctly, according to your benefits. The Plan reviewed call history and found 
a Plan representative advised you on April 2, 2021. During this call, the representative told you that if you have 
an office visit, you would not be held responsible for a copayment. However, services rendered in a hospital 
setting would result in charges. The Plan also says that neither you nor your provider contacted the Plan to 
verify benefits and coverage for outpatient services. 
 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 $370 
copayment for Outpatient Surgery, including services provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $370 copayment for outpatient services which fall within the Outpatient Surgery, 
including services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgical services provided by an in-network 
hospital on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of abdomen and 
pelvis (74176). 
 
You asked the Plan to pre-approve CT scan services. You say that these imaging services are necessary. The 
Plan denied your request. The Plan says the criteria for coverage of the requested CT scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scan services. Our reviewer says 
that the requested imaging service is not medically reasonable and necessary. Our physician reviewer found the 
review indicates that your abdominal exam is normal, and your urinalysis was normal. There is no specific 
clinical rationale for the requested CT scan. The requested CT scan is not 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 CT scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) scan of abdomen and pelvis (74176).
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pre-approve CYP2C19 testing for the enrollee.
You asked the Plan to pre-approve CYP2C19 testing. You say that this testing is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the reopen request and the case file. At issue is coverage for CYP2C19 genetic
testing. The Physician Reviewer determined that although the enrollee has not had an MRI, he has
had end organ disease as a result of vascular disease and this test will help see if this enrollee is a likely nonresponder
or poor responder. The Plan requested a re-opening, citing an error on the face of the evidence. The
Plan has stated that it disagrees with our consultant's determination. The Plan argues that the Maximus
physician reviewer did not apply the coverage guidelines established by Medicare that state that CYP2C19
testing is considered investigational for all indications other than ACS undergoing PCI.
Based on the medical records, the Plan is correct in this case. The enrollee is a 75-year-old man with a
diagnosis of cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries.
The Medicare LCD L35062, Biomarkers Overview, limits CYP2C19 genetic testing to patients with acute
coronary syndrome who are undergoing percutaneous coronary interventions and are initiating or reinitiating
Clopidogrel (Plavix) therapy. Genetic testing for the CYP2C19 gene is considered investigational at this time
for all other indications.
Therefore, per the documentation in the case file, the LCD coverage criteria were not met for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve CYP2C19 testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
You asked the Plan to pre-approve the out-of-network ophthalmology services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are in-network providers that are available to service the member.
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 pre-approve 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 has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.