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

We decided that the Plan does not have to waive the $215.19 cost share for a colonoscopy with polyp removal
provided on June 24, 2021.
You asked the Plan to waive this cost share. You say that this colonoscopy was a screening and should be no
charge. The Plan denied your request. The Plan says this was a second procedure due to failure of a previous
screening. The records show the second procedure resulted in removal of and biopsy of an 8mm sessile polyp.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that this procedure resulted in
removal and biopsy of a polyp which is a separate procedure from the screening which requires cost share.
The Plan is correct in this case. 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 any services resulting from the colorectal screening that become
diagnostic in nature will result in a cost share. Services such as polyp removal and biopsy require cost share.
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 $215.19 cost share for a colonoscopy with polyp removal
provided by Einstein Gastroenterology Associates on June 24, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on May 21, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollee was enrolled in hospice at the time of services. The Plan states per 
Medicare guidelines, the enrollee's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for inpatient hospital care provided on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
CPT 95907: 
 Nerve conduction studies; 1-2 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 95885, this 
procedure is "done with nerve conduction studies" per CPT code description.  In this case, nerve conduction 
studies cannot be verified, therefore this procedure would not be covered. In terms of CPT 95907, the 
procedure report describes pedicle screw stimulation. In this case, nerve conduction studies would not be 
reported for procedure performed.  Nerve conduction studies measure amplitude; latency, and conduction 
velocity. Therefore this procedure cannot be verified. In terms of CPT 95937, the procedure report does not 
include documentation of neuromuscular junction testing. In terms of CPT 95955, this procedure is listed as 
"Special electroencephalogram (EEG) tests"; the procedure report does not include documentation of EEG 
during nonintracranial service in addition to the primary neuromonitoring procedure. Therefore this procedure 
cannot be verified. 
 
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
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 4 home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional home health services. You say that you believe more home 
health services are needed. The Plan denied your request. The Plan says the requested care is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. 
Our reviewer says that the requested number of home health visits is not medically reasonable and necessary. 
Our physician reviewer found the enrollee does not have documented, ongoing PT needs. The enrollee has 
reached a plateau in function. The enrollees care needs are custodial. Ongoing PT services are not medically 
necessary or reasonable. 
 
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 additional home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an additional 4 home health physical therapy (PT) visits.
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 kit. 
 
You asked the Plan to pre-approve a Freestyle Libre (CGM) sensor. You say that the device is medically 
necessary. 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, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. 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 
kit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 26, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found these 
procedures overlap CPT 22633. It is appropriate to report these codes separately when documentation supports 
additional work for decompression, or the service is performed at a different level. The operative report does 
not document the additional work or a different level was performed. 
 
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 surgical services provided to the enrollee on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the frames (CPT code V2020), the photochromatic tint (CPT code 
V2744), and the progressive lens (CPT code V2781) provided on September 14, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you were never told you had a maximum benefit of 
$400.00 and were never told by the provider your limit. The Plan denied your request. The Plan says that the 
claim for services provided on September 14, 2021, processed correctly. 
 
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 an explanation of benefits or any documentation to 
verify what you have already paid towards your benefit. Therefore, we do not know what you owe and what 
you had left of your benefit. Therefore, we decided that the Plan has to pay for the frames (CPT code V2020), 
the photochromatic tint (CPT code V2744), and the progressive lens (CPT code V2781) provided on 
September 14, 2021.  
 
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 pathology services (88305) billed to the enrollee for date of
service May 22, 2021.
You asked the Plan to pay for code 88305. You say that this claim should be paid. The Plan denied your
request. The Plan says this service was previously paid. Maximus overturned for a lack of claim information in
the case file to show previous payment. The Plan requested a reopen and provided proof of previous payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the Plan provided documentation to show code 88305 was previously
paid. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does
not have to pay for pathology services (88305) billed to the enrollee for date of service May 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab tests received on November 5, 2021. 
 
You asked the Plan to waive the coinsurance for lab tests. You say that you don't feel that this is something you 
should be responsible for as it is lab tests for routine cervical cancer screening. The Plan denied your request. 
The Plan says the coinsurance was applied 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 30% 
coinsurance after the deductible is met for diagnostic lab services and diagnostic procedures and tests (per day, 
per facility) for lab tests. 
 
 
  You have been asked to pay a total of $18.50 for lab tests.  
 
Service Allowed Amount Standard Coinsurance Member Liability 
Human Papillomavirus Test $35.09 30% $10.52 
Cytopathic Test $26.61 30% $7.98 
TOTAL:   $18.50 
 
Lab tests 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 coinsurance for lab tests received on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Prodigy Glucometer, Prodigy test strips, Prodigy control 
solution, and Truplus lancets provided to the enrollee on March 27, 2020. 
 
You asked the Plan to pay for the items. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee does not utilize an insulin pump, does not require a talking meter, and is not 
mentally-impaired limiting ability to be retrained on a new device. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that the enrollee does not need these items. The enrollee does not specifically need 
the LifeScan brand for these products. 
 
 
 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 items have not been met. Therefore, we decided that the Plan does not have 
to pay for a Prodigy Glucometer, Prodigy test strips, Prodigy control solution, and Truplus lancets provided to 
the enrollee on March 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has had long-term 
disabling pain for more than six months that affects the quality of his quality life. You say that conservative 
methods have been unsuccessful in providing relief. The Plan denied your request. The Plan says current 
medical literature indicates that the requested procedure is considered experimental and investigational and is 
not identified as widely used and generally accepted for the proposed use as reported in nationally recognized 
peer-reviewed medical literature published in the English language. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the epidural injection provided on July 19, 2021. 
 
You asked the Plan to pay for the epidural injection. You say that this was a medically necessary treatment. 
The Plan denied your request. The Plan says that the provider has not submitted clinical records to support the 
medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the epidural injection. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this 75 year old woman has chronic back pain and has a functioning intra-thecal pump. This injection 
was made through the intrathecal catheter. The procedure was medically reasonable and necessary as part of 
intra-thecal therapy. 
 
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 epidural injection have been met. Therefore, we decided that the Plan has to 
pay for the epidural injection provided on July 19, 2021.  
 
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: 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. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that the 
enrollee's needs can be safely met in a less intensive setting. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is 
being treated as an outpatient with immunotherapy for metastatic renal cell cancer and is receiving outpatient 
home health physical therapy services. There is ongoing weakness. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 a Freestyle Libre continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says you do 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 or 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 (K0553).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF.  As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
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 skilled nursing facility (SNF) care.