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

 
We decided that the Plan does not have to pay for the blood draw (36415), complete blood count (85025), 
comprehensive metabolic panel (80053), and travel allowance for medically necessary laboratory services 
(P9603) provided on September 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on 
this date. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the blood draw 
(36415), complete blood count (85025), comprehensive metabolic panel (80053), and travel allowance for 
medically necessary laboratory services (P9603) provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for contact lens fitting provided on January 
18, 2022. 
 
You asked the Plan to make additional payment for contact lens fitting. You say that you are requesting full 
payment. The Plan denied your request. The Plan says the Plan has paid the full allowable amount for this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
additional payment of contact lens fitting have not been met. Specifically, the record indicates that the Plan has 
paid the Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed 
amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to make additional payment for 
contact lens fitting provided on January 18, 2022.
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 you feel the enrollee is appropriate for 
the long-term acute care hospital level of care and is necessary to function at optimal level. The Plan denied 
your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DCISionRT protein expression profiling (0295U) 
provided on June 29, 2022. 
 
You asked the Plan to pay for the DCISionRT testing. You say that this testing is medically necessary, and the 
testing is not experimental. The Plan denied your request. The Plan says your request does not meet Medicare 
rules because a review of the medical literature and clinical practice guidelines does not support the clinical 
utility of this testing of multiple biomarkers in someone with DCIS. 
 
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 DCISionRT testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that molecular profiling of DCIS is not considered a standard of care. Use is not 
supported by the National Comprehensive Cancer Network (NCCN) Guidelines. The NCCN Guidelines 
recommends using the definition of low-risk DCIS from the RTOG 9804 trial to stratify patients that may be 
able to avoid radiation after surgery if endocrine therapy is intended. This is based on a screen-detected DCIS, low to intermediate nuclear grade, tumor size =2.5 cm, and surgical resection with margins negative at >3 mm. 
The service is not reasonable or 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 the DCISionRT testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the DCISionRT protein expression profiling (0295U) provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chiropractic services and prosthetic devices 
provided from March 3, 2021, to April 7, 2021. 
 
You asked the Plan to waive the cost share for chiropractic services and prosthetic devices. 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 $20 
copayment per chiropractic services and a 20% coinsurance for Medicare covered prosthetic devices. 
 
 You have been asked to pay a total of $122.17 copayment for chiropractic services and prosthetic devices. The 
chiropractic visits fall within the Chiropractic services benefit category. The prosthetic devices fall within the 
Prosthetic devices and related 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 cost share 
for chiropractic services and prosthetic devices provided from March 3, 2021, to April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution 
injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization 
(includes contrast when administered), multiple adhesiolysis sessions; 1 day (CPT code 62264). 
 
You asked the Plan to pre-approve the service. You say that the procedure is indicated as part of a 
multidisciplinary approach to the treatment of the disabling condition of failed low back syndrome. The Plan 
denied your request. The Plan says Medicare considers epidural lysis of adhesions to be a procedure that is not 
medically necessary because it is an experimental and investigational procedure. 
 
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 pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure. The request is 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, 
enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when 
administered), multiple adhesiolysis sessions; 1 day (CPT code 62264).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 4, 2021, to 
August 16, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says 
the DRG submitted on this claim is not supported by the medical records provided. 
 
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 sepsis, unspecified organism (A41.9). 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 this diagnosis is not supported in the medical record. Our physician reviewer found that 
the enrollee was treated in the hospital with a hip fracture. The provided records described the enrollee as 
hemodynamically stable following initial treatment with fluids, with normal liver, kidney, platelet, and lung 
function. She had dementia at baseline with superimposed delirium related to fall and narcotic use. However, 
there was insufficient evidence provided showing there was sepsis based on the Sepsis 3 criteria which requires 
Sequential Organ Failure Assessment (SOFA) of 2+ and signs of a dysregulated response to the infection 
causing direct organ damage without other cause of the abnormalities. Therefore, the diagnosis of sepsis is not 
supported in the documentation. 
 
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 provided on August 4, 2021, to August 16, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on September 6, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you disagree with the copayment. 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 $225 
copayment for outpatient diagnostic tests/each Medicare-covered diagnostic radiology service.  
 
You have been asked to pay a $225 copayment for MRI. However, you are only being asked to pay$216.82 
which is less than the required amount. This item/service falls within the outpatient diagnostic tests/each 
Medicare-covered diagnostic radiology service 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 magnetic resonance imaging (MRI) provided on September 6, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the copayments for diabetes training and DME provided from September 
6, 2022, to September 28, 2022. 
 
You asked the Plan to waive the copayments for diabetes training and DME. You say that this should be 
covered. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 coinsurance for Durable medical equipment (DME) and 
related supplies and a $0 copayment for diabetes self-training. 
 
The Plan says you must pay 20% coinsurance for DME and pay towards your deductible for the diabetes 
training. Based on the Plan contract, however, you cannot be asked to pay more than $0 for diabetes training 
and DME. Therefore, we decided that the Plan has to waive the copayments for diabetes training and DME 
provided from September 6, 2022, to September 28, 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: Practitioner Services
Decision: Favorable

We decided the Plan must pay for out of network methadone treatment and counseling services provided from
November 1, 2021, to November 29, 2021.
You asked the Plan to pay for this treatment. You stated that the enrollee was referred for this treatment by his
physician. You stated this is a daily dosing and counseling program for Methadone treatment and you are
currently the only provider in the enrollee's area who provides the type of treatment program the enrollee is
part of. The Plan denied your request. The Plan says these services can be provided in network and the enrollee
has been redirected to a provider in network. Maximus upheld the Plans decision. After the Plan requested a
reopen on another case for this enrollee, Maximus was required to review all the cases regarding this service.
During the review, Maximus asked the Plan for additional information regarding when the enrollee began
methadone treatment and who ordered the treatment. Maximus also asked for a list of providers within a
reasonable driving distance of the enrollee's home that could provide treatment. Once this information was
submitted the appeal went to medical review.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for methadone
maintenance treatment. The enrollee has been enrolled in an Opioid Treatment Program (OTP) since March
2020 and began with your facility in January 2021. The medical records show the enrollee is a 66-year-old man
with diagnoses of Opioid Dependence Uncomplicated, and other problems related to lifestyle. The enrollee has
been receiving out of network maintenance methadone daily for chronic pain.
The Plan referred the enrollee to an in-network provider. A map review shows that this office is 32.5 miles
away from the enrollee's residence. The additional list of providers shows no closer alternatives are identified.
If the enrollee is to travel to the addiction program office daily to receive the needed medication, a 65 plus mile
round trip daily is not reasonable.
The rules say that plans must ensure continuity of care for enrollees. We looked at this physician's review, the
file, the Medicare rules, and the additional information submitted by the Plan. We also referenced Google Maps
and MapQuest when checking the list of providers submitted by the Plan that were stated to be able to treat the
enrollee. Based on this information, we decided that Medicare rules for coverage the requested treatment have
been met. Therefore, we decided that the Plan must pay for out of network methadone treatment and counseling
services provided to the enrollee from November 1, 2021, to November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the powered air flotation bed (low air loss therapy) 
(E0193) and alternating pressure mattresses or low air loss mattresses (E0277). 
 
You asked the Plan to pre-approve the hospital bed and mattress. You say that the hospital bed will allow you 
to sleep more comfortably and will help easy your chronic back pain. The Plan denied your request. The Plan 
says The enrollee does not meet the CMS guidelines for an electric hospital bed or a pressure reducing 
mattress. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed and mattress. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, the documentation does not support that the enrollee has a 
condition that requires frequent positioning of the bed and mattress to alleviate pain, promote good body 
alignment, prevent contractures or avoid respiratory infections in a way that an ordinary bed is not able to. 
Additionally, the documentation doesn't indicate the enrollee has any pressure injuries to the skin or is at risk of 
pressure injuries to the skin.  
 
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 hospital bed and mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the powered air flotation bed (low air loss therapy) (E0193) and alternating 
pressure mattresses or low air loss mattresses (E0277).
Appeal type: Drugs
Decision: Favorable

We decided the Plan must pay for out of network methadone treatment and counseling services provided from January 26, 2021, to September 27, 2021.
You asked the Plan to pay for this treatment. You stated that the enrollee was referred for this treatment by his physician. You stated this is a daily dosing and counseling program for Methadone treatment and you are currently the only provider in the enrollee's area who provides the type of treatment program the enrollee is part of. The Plan denied your request. The Plan says these services can be provided in network and the enrollee has been redirected to a provider in network. Maximus upheld the Plans decision. After the Plan requested a reopen on another case for this enrollee, Maximus was required to review all the cases regarding this service. During the review, Maximus asked the Plan for additional information regarding when the enrollee began methadone treatment and who ordered the treatment. Maximus also asked for a list of providers within a reasonable driving distance of the enrollee's home that could provide treatment. Once this information was submitted the appeal went to medical review.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for methadone maintenance treatment. The enrollee has been enrolled in an Opioid Treatment Program (OTP) since March 2020 and began with your facility in January 2021. The medical records show the enrollee is a 66-year-old man with diagnoses of Opioid Dependence Uncomplicated, and other problems related to lifestyle. The enrollee has been receiving out of network maintenance methadone daily for chronic pain.
The Plan referred the enrollee to an in-network provider. A map review shows that this office is 32.5 miles away from the enrollee's residence. The additional list of providers shows no closer alternatives are identified. If the enrollee is to travel to the addiction program office daily to receive the needed medication, a 65 plus mile round trip daily is not reasonable.
The rules say that plans must ensure continuity of care for enrollees. We looked at this physician's review, the file, the Medicare rules, and the additional information submitted by the Plan. We also referenced Google Maps and MapQuest when checking the list of providers submitted by the Plan that were stated to be able to treat the enrollee. Based on this information, we decided that Medicare rules for coverage the requested treatment have been met. Therefore, we decided that the Plan must pay for out of network methadone treatment and counseling services provided to the enrollee from January 26, 2021, to September 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 8, 2022, to 
February 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 8, 2022, to 
February 6, 2022.