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

 
We decided that the Plan does not have to pay for a radiologic examination, chest (code 71045) and diagnostic 
imaging procedures of the lower extremities (code 73502) provided on July 30, 2022. 
 
You asked the Plan to pay for the radiologic examination, chest and diagnostic imaging procedures of the lower 
extremities. The Plan denied your request. The Plan says Original Medicare would be responsible for payment 
of all Medicare covered services related or unrelated to the members terminal condition. The Medicare 
hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to 
the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending 
physician services and all care unrelated to the terminal illness until the first day of the month following the 
month in which hospice was revoked or discharged. 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 a radiologic examination, chest (code 71045) and diagnostic 
imaging procedures of the lower extremities (code 73502) provided on July 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 x 4 provided from August 8, 2022, to 
August 11, 2022. 
 
You asked the Plan to pay for procedure code 99233 x 4. You say that the medical records support the billing 
of code 99233 provided on August 8, 9, 10, and 11, 2022. The Plan denied your request. The Plan says the 
medical records do not support the billing of code 99233 provided on August 8, 9, 10, and 11, 2022. 
 
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 code 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99233 x 4. Our reviewer says that the 
medical records do not support the billing of code 99233 provided on August 8, 9, 10, and 11, 2022. Our 
reviewer found procedure code 99233 is not supported for the dates of service in question. The medical records 
submitted do not state the date of service. It cannot be verified that the services were performed on the dates 
billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 x 4 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 x 4 provided from August 8, 2022, to August 11, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 17, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan demonstrated that they agree concur that 2
chest x-rays were completed on May 17, 2022. Code 71045(26) was paid on June 23, 2022. The second chest
x-ray under code 71045(26) was paid on June 27, 22. Therefore, no further payment is due.
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 the claims billed were paid.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for imaging services provided to the enrollee on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Liquid Biopsy panel (81455) provided to the
enrollee on May 19, 2022.
You asked the Plan to pay for the Tempus Liquid Biopsy panel. You say that this was medically necessary. The
Plan denied your request. The Plan says that this was not billed correctly.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of
service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An
independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen
was not collected in an independent laboratory.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Liquid Biopsy
panel (81455) provided to the enrollee on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard screening test. 
 
You asked the Plan to pre-approve a Cologuard screening test. You say that colon cancer runs in the family and 
colonoscopies are typically not recommended over the age of 80. The Plan denied your request. The Plan says 
this test is not covered because you are over 85. 
 
The Plan must follow Medicare rules. Medicare rules say that this test may be covered for enrollees between 
the ages of 50 to 85 years. 
 
We looked at the file and Medicare rules. You are over the age of 85. Based on this information, we decided 
that Medicare rules for coverage of a Cologuard screening test have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Cologuard screening test.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says that the criteria for coverage were not met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Aranesp. Our physician reviewer found that the enrollee has chronic kidney disease. The enrollee has received Ferraheme. Drug compendia, Micromedex does not exclude the requested use with iron deficiency. Aranesp packaging instructs to evaluate the iron status in all patients before and during treatment and maintain iron repletion. Correct or exclude other causes of anemia (e.g., vitamin deficiency, metabolic or chronic inflammatory conditions, bleeding, etc.) before initiating Aranesp [see Warnings and Precautions (5.10)]. Because Ferraheme has been used to correct iron deficiency, the documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have been met. Therefore, we decided that the Plan has to pre-approve Aranesp.

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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox 100-unit injection (J0585). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 medication. Our physician reviewer 
found based on the medical records provided and the Medicare-approved major drug compendia there is no 
documentation that the Botox at issue in this case meets all of Medicare's LCD criteria for medically reasonable 
and necessary and safe and effective for the enrollee. Provided medical records do not document a medically 
accepted indication for use of Botox for the enrollee's anal muscle spasms. As stated in the LCD: "Coverage of 
botulinum toxin for certain spastic conditions (e.g., cerebral palsy, stroke, head trauma, spinal cord injuries, 
and multiple sclerosis) will be limited to those conditions listed in the Billing and Coding: Botulinum Toxin 
Type A & B (A57474).  All other uses in the treatment of other types of spasm will be considered as 
investigational and therefore, non-covered by Medicare." Anal muscle spasm is not listed in the Billing and 
Coding: Botulinum Toxin Type A & B (A57474) or in the Medicare-approved major drug compendia as a 
medically accepted indication for use of Botox. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox 100-unit injection (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Hyaluronan or derivative, GenVisc 
850, for intra-articular injection, 1 mg provided from September 29, 2022 to October 10, 2022. 
 
You asked the Plan to waive the coinsurance for the Hyaluronan or derivative, GenVisc 850, for intra-articular 
injection, 1 mg. You say that at no time were you told by the Plan or the provider's office that you would have 
to cover any of the cost beyond your $15 office 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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
 You have been asked to pay a 20% coinsurance for the Hyaluronan or derivative, GenVisc 850, for intra-
articular injection, 1 mg. This service falls within the Medicare Part B Prescription Drugs 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 the Hyaluronan or derivative, GenVisc 850, for intra-
articular injection, 1 mg provided from September 29, 2022 to October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee would benefit from a shower chair 
due to their medical complexity. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 5, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
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 psychotherapy 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 psychotherapy provided on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the wrist brace provided on October 6, 
2022. 
 
You asked the Plan to waive the cost sharing for the wrist brace. You say that you would like the cost sharing 
to be lower. 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 20% 
coinsurance for Medicare-covered durable medical equipment. 
 
You have been asked to pay a cost share of $38.83 for the wrist brace ($194.15 allowed amount x .20 = 
$38.83). This item/service falls within the durable medical equipment (DME) 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 sharing for the wrist brace provided on October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the F1 Heme testing provided to the enrollee on January 28, 2022.
You asked the Plan to pay for the testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says that this specimen was not taken by the laboratory directly.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the F1 Heme testing provided to the enrollee on January 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Opdivo.

You asked the Plan to pre-approve Opdivo. You say that you are appealing with records. The Plan denied your request. The Plan says there is no documentation of PD-L1 expression of at least 5, nor indication that it will be used in combination with chemotherapy.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Opdivo. Our reviewer says that the enrollee does not meet the criteria for Opdivo. Our physician reviewer found treatment options for the enrollee's condition include Folfox and Opdivo in combination, but not Opdivo alone. This use of Opdivo is not Food & Drug Adminsitration (FDA) approved for the enrollee's diagnosis. This use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, chest (code 71046) provided on 
October 14, 2022. 
 
You asked the Plan to pay for the radiologic examination, chest. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the Plan requires utilization of network providers when 
possible and available and requires authorization for certain services. No medical necessity for an out-of-
network provider such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a radiologic examination, chest (code 71046) provided on 
October 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an electrophysiological procedure provided 
on August 16, 2022. 
 
You asked the Plan to reduce the cost share for an electrophysiological procedure. You say that this procedure 
should have been considered outpatient surgery. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for in-network diagnostic procedures and tests at an outpatient hospital.  
 
According to Medicare, an electrophysiological procedure is considered a diagnostic cardiology procedure. The 
enrollee has been asked to pay $2,654.19, which is 20% of the allowed amount for an electrophysiological 
procedure ($21,609.01 allowed amount x 20% coinsurance = $2,654.19). This item/service falls within the in-
network outpatient diagnostic tests benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the cost 
share for an electrophysiological procedure provided on August 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual care telehealth visits provided from August 10, 2022 
to November 2, 2022. 
 
You asked the Plan to pay for virtual care telehealth visits. The Plan denied your request. The Plan says the 
care is available in Plan. Virtual care telehealth visits are not covered out-of-network. 
 
The Plan contract says that the Plan does not cover virtual care telehealth out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care telehealth 
out-of-network. Based on this information, we decided that Plans rules for coverage of virtual care telehealth 
visits have not been met. Therefore, we decided that the Plan does not have to pay for the virtual care telehealth 
visits provided from August 10, 2022 to November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 8, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan the claim was billed with a place of
service (POS) 81. Only an independent laboratory taking a sample in its laboratory shows an 81 POS code.
The medical records show the specimen was collected in the hospital. Medicare billing criteria are not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim was
not submitted with an appropriate POS code. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 8,
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 19, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
October 19, 2022.