Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the records provided support the need for the 
requested device. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) with chronic bronchitis and frequent exacerbations. There is no diagnosis of cystic 
fibrosis, bronchiectasis, or neuromuscular disease. This device has not been shown to be beneficial in the 
treatment of COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
December 6, 2021. 
 
You asked the Plan to waive the copayment for the mammogram. You say that you thought all mammograms 
were free. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 no 
coinsurance or copayment for screening mammograms once per year. 
 Your contract with the Plan also clearly says that you must pay a $45 copayment for routine radiology services. 
 
The file shows that this mammogram was done within the one year timeframe from your previous 
mammogram on March 29, 2021. Therefore, you have been asked to pay a $45 copayment for the 
mammogram. The mammogram 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 a diagnostic mammogram 
provided on December 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on November 18, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that these services were medically 
necessary and should be covered. The Plan denied your request. The Plan says there was no documentation that 
the psychologist consulted with the primary care/attending physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on November 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (PSG); age 6 years or older, sleep 
staging with 4 or more additional parameters of sleep, attended by a technologist (CPT code 95810). 
 
You asked the Plan to pre-approve the sleep study. You say that you are requesting this service due to the 
enrollee's breathing issues. The Plan denied your request. The Plan says this test could be done at home and the 
enrollee could also try an auto-titrating machine to treat their problem. The Plan states the enrollee's doctor 
would need to request this testing. 
 
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 sleep study. Our physician reviewer 
found additional information is needed before a PSG can be approved. If the results of the previous study can 
be obtained and there has been no substantial change in the enrollee's weight, a trial of auto-continuous positive 
airway pressure (CPAP) would be reasonable. The denial is upheld. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve polysomnography (PSG); age 6 years or older, sleep staging with 4 or more additional 
parameters of sleep, attended by a technologist (CPT code 95810).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on September 14, 2021. 
 
You asked the Plan to pay for the lab testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this was not billed with an appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab testing have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the lab testing provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from November 10, 2020, to 
November 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not 
supported. 
 
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 diagnosis code J96.01. 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 use of diagnosis code J96.01 is 
not supported by the records provided. Our physician reviewer found that although intubation for airway 
protection, and respiratory failure is consistently documented during hospital stay, mechanical ventilation was 
initiated. In this case, the enrollee's respiratory system could not oxygenate and/or ventilate without assistance. 
Initially, the enrollee was intubated for "airway protection" giving gas exchange without intervention, then 
additional assistance was necessary, and therefore acute respiratory failure would be supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for 
the inpatient services provided from November 10, 2020, to November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from June 23, 2021, to 
June 25, 2021, billed with principal diagnosis code A41.51. 
 You asked the Plan to pay for the inpatient care as billed. You say that this was billed at the appropriate DRG. 
The Plan denied your request. The Plan says the records do not support the reported diagnosis of sepsis. 
 
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 principal diagnosis code A41.51, defined as sepsis 
due to escherichia coli. 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 care as billed. 
Our reviewer says that the documentation does not support the billed principal diagnosis. Our physician 
reviewer found the emergency room physician documented the patient to have complaints of increased fatigue, 
weakness, and a fall. She was found to be febrile with decreased blood pressure, but other vital signs were 
normal. Even though sepsis is documented, supporting medical record documentation was not found within the 
record. The review has determined that the medical records do not support the billing of sepsis due to 
Escherichia coli (A41.51).  
 
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 the inpatient hospital care provided from June 23, 2021, to June 25, 2021, billed with principal diagnosis 
code A41.51.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95910, 95886, 95999) provided on August 2, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 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 services. Our reviewer says that the use of codes 95910, 
95886, and 95999, is not supported by the records provided. Our reviewer found that for code 95910, the 
technical report describes pedicle screw stimulation, which would not be reported with nerve conduction 
studies, which measure amplitude,  latency/velocity. Therefore this procedure cannot be verified. For code 
95886, this procedure is per CPT code description "done with nerve conduction". Therefore this procedure 
cannot be verified, as nerve conduction studies are not supported. For code 95999, the provider is reporting an unlisted procedure for Train of Four. A procedure code does not exist for Train of Four testing, as it is inclusive 
to IONM procedure code, and would not be reported separately. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (95910, 95886, 95999) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve the RFA services. You say that the medical records provided support the 
need for RFA at spinal level T5-6. The Plan denied your request. The Plan says there is no documentation of 
necessity for the second procedure. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic MBB that produces 
at least 80% pain relief is required for coverage of therapeutic facet joint procedures. 
 
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 RFA services.  Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
has mid thoracic back pain. The enrollee has had previous RFA at another thoracic level. He had a single set of 
diagnosis medial branch blocks (MBBs) at T5-T7 on February 22, 2022, which gave him 100% pain relief for 1 
day. There is no documentation of a second confirmatory diagnostic MBB. Medicare rules for coverage require 
a second confirmatory diagnostic MBB that produces at least 80% pain relief. 
 
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 RFA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
You asked the Plan to pre-approve this service. You say that this treatment 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 applied the wrong criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bioimpedance
spectroscopy. The Maximus Physician Reviewer determined that the evidence suggests that monitoring with
bioimpedance spectroscopy (BIS) allowing for early intervention significantly reduces the relative risk of
chronic breast cancer-related lymphedema (BCRL) with a 69% and 81% reduction compared to background
and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to
chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to
detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients. The Plan
requested a reopen and argues the evidence is insufficient to determine that the technology results in an
improvement in the net health outcome. The medical records show the enrollee is a 71-year-old woman with a
diagnosis of invasive lobular breast carcinoma, ER/PR positive, HER2 negative. This is her second diagnosis
of breast cancer. The provider writes that in her opinion, the enrollee is at high risk of developing lymphedema
as the result of treatment.
Our Medical Director has concluded that the Plan is correct. The evidence in the medical literature at this time
is insufficient to support that bioimpedance spectroscopy was medically reasonable and necessary for the
enrollee 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 this service have not been met. Therefore, we
decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on April 14, 2021, by an out-of-network 
provider. 
 
You asked the Plan to pay for the dental services. You say that you thought this dentist was in-network. The 
Plan denied your request. The Plan says that this dentist is not in-network with the Plan's supplemental dental 
vendor's network. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not forward the correct 2021 Evidence of Coverage to verify your 
dental benefits. Therefore, we decided that the Plan has to pay for the dental services provided on April 14, 
2021, by an out-of-network provider.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from September 16, 2021, and 
January 31, 2022, by an out-of-network provider.  
You asked the Plan to pay for the dental services. You say that you have seen this provider for over fifteen (15) 
years. The Plan denied your request. The Plan says you received self-referred services from a provider that is 
not the supplemental dental vendor's participating provider. The Plan states you received dental care from a 
provider that is not part of the supplemental dental vendor's network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the dental services provided from September 16, 
2021, and January 31, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the enrollee is not able to check 
her blood glucose the standard way. The enrollee needs to be able to monitor her blood glucose on her own. 
The Plan denied your request. The Plan says the enrollee does not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM) sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone grafting (CPT code(s): D7953 and D4266) provided on 
December 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you needed this not as a cosmetic procedure, but 
the partial to hold the remaining teeth you have, and without it they will lose their stability and fall out. The 
Plan denied your request. The Plan says the services are not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. The services are not listed in your 2021 EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for bone 
grafting (CPT code(s): D7953 and D4266) provided on December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Triage testing provided on November 17, 
2021. 
 
You asked the Plan to pay for the CxBladder Triage testing. You say that this is medically necessary testing 
that is valuable to the treating physician. The Plan denied your request. The Plan says the Cxbladder testing 
was done for screening purposes and is not covered when performed for an enrollee with asymptomatic 
microscopic hematuria. 
 
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 CxBladder Triage testing. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found CxBladder is considered experimental/investigational as a screening test for 
urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy, and upper tract imaging will still be necessary 
regardless of the results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-
negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is 
poor for low-stage and low-grade tumors.   
 
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 CxBladder Triage testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the CxBladder Triage testing provided on November 17, 2021.