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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three (3) power wheelchair with one power 
option and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with one power option and accessories. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested device 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that group three wheelchairs with one power option 
and accessories are only covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee is not considered high 
risk for skin breakdown on sitting surfaces and there is no history of current or previous skin breakdown. 
There is no documentation of flap surgery. There is no documentation of spasticity or self-catheterization 
to meet recline criteria. The enrollee has no increased tone or spasticity in the trunk or lower extremities. The 
enrollee's requires contact guard assistance with getting  in and out of a car. Based on this information, we 
decided that Medicare rules for coverage of a group three power wheelchair with one power option and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group three 
(3) power wheelchair with one power option and accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance -air provided on June 08, 2022. 
 
You asked the Plan to waive the coinsurance for ambulance -air. You say that you cannot afford this charge. 
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% 
coinsurance for Ambulance Services. 
 
You have been asked to pay 20% coinsurance for ambulance -air. This item/service falls within the Ambulance 
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 coinsurance for ambulance -air provided 
on June 08, 2022. 
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on August 20, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for Lab services. 
 
You have been asked to pay a $15 copayment for laboratory services. This item/service falls within the Lab 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services 
provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT.) 
 
You asked the Plan to pre-approve PBRT. You say that PBRT would provide the enrollee with the best chance 
of reducing post-treatment complications. The Plan denied your request. The Plan says there is insufficient 
evidence that proton beam therapy offers improved treatment efficacy or improved long-term toxicity 
compared with intensity modulated radiotherapy. 
 
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 PBRT. Our reviewer says that PBRT is 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is 
insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, intensity-
modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. Recent data shows 
no significant differences in late (years one, two, and three) patient-reported toxicity outcomes between proton 
beam therapy and IMRT.  The most recent American Urological Association (AUA) and National 
Comprehensive Cancer Network (NCCN) guidelines state that PBRT offers no clinical advantage over other forms of definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT.)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot insert (CPT code L3000). 
 
You asked the Plan to pre-approve the foot insert. You say that a suitable custom-made insert pad in the shoe to 
adjust your foot will help you with walking and balance. The Plan denied your request. The Plan says this item 
is not a covered benefit. Medicare rules state that supportive devices for the feet (such as orthotics) are only 
covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these 
same rules. Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. 
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics 
for your condition. Therefore, we decided that the Plan does not have to pre-approve the foot insert (CPT code 
L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
have complex care needs that require a coordinated team approach. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute care hospital for thrombo-embolectomy of the lower extremities. 
Medical problems are stable. The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (CPT code E2377), harness for 
upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or 
more power seating system motors (E2311) and Pelvic Obliquity Kit (K0108). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  
  
The seat lift does not serve a medical purpose. E2377 Expandable Controller, E2313 Expandable Controller 
Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt, 
recline and power elevating leg rests through the joystick. The notes state that these are needed when 3 or more 
actuators are being used. The electrical connection between the wheelchair controller and two or more motors 
(E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three 
approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The enrollee has 4/5 left hand and wrist strength with normal 
ROM. This upper limb strength and function are adequate for the member to be able to control the power 
options using their own switches which are included in the allowance of these power options. The requested 
Pelvic Obliquity Kit is included with the wheelchair cushions. This cannot be requested separately. Therefore, 
we decided that the Plan does not have to pre-approve expandable controller (CPT code E2377), harness for 
upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or 
more power seating system motors (E2311) and Pelvic Obliquity Kit (K0108).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 8, 2022.
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 enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
23, 2022, to April 14, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Specialist office visits. 
 
You have been asked to pay a $25 copayment for specialist office visit. This item/service falls within the 
Specialist 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. You have been asked to pay $50 ($25 x 2 visits) copayment for your specialist visits. 
Therefore, we decided that the Plan does not have to waive the copayment for specialist office visit provided on 
March 23, 2022, to April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit provided on September 16, 
2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you shouldnt have to pay a 
deductible. 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 $750 
deductible for Office visits. 
 
You have been asked to pay a $750 deductible for office visit. This item/service falls within the 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. At the 
time the claim was received your deductible had not yet been met so you have been asked to pay $68.81 
towards your deductible. Therefore, we decided that the Plan does not have to waive the deductible for office 
visit provided on September 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of exudative age-related macular degeneration and has previously been 
treated with Eylea. The documentation does not support that the enrollee has tried and failed bevacizumab 
(Avastin). The documentation does not support that bevacizumab (Avastin) would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the receiver (monitor), dedicated, for use with therapeutic glucose 
continuous monitor system (K0554) and supply allowance used with a therapeutic CGM device (K0553). 
 
You asked the Plan to pre-approve the Freestyle Libre CGM and supplies. You say that you have 2 fingers, and 
it is hard for you to use a regular glucose meter. The Plan denied your request. The Plan says that the enrollee 
is not on a sliding scale and does not require frequent adjustments to her insulin regimen based on blood sugar 
determinations. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 Freestyle Libre CGM and supplies. 
Our reviewer says that the requested items/services is considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee's lack of digits/hand would likely make it hard for the enrollee 
he to monitor blood glucose with finger sticks and traditional glucometer; hence the CGM should be covered. 
 
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 Freestyle Libre CGM and supplies have been met. Therefore, we decided 
that the Plan has to pre-approve the receiver (monitor), dedicated, for use with therapeutic glucose continuous 
monitor system (K0554) and supply allowance used with a therapeutic CGM device (K0553).  
 
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 lab services provided on June 24, 2022. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for lab services provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 20, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you provided medical documentation to be 
reviewed for reconsideration of payment denial. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on July 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on July 02, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $240 
copayment for Ambulance services. 
 
You have been asked to pay a $240 copayment for ambulance transport. This item/service falls within the 
Ambulance 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 ambulance transport 
provided on July 02, 2022.