Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 4, 2022, to October 7, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that your experience was so 
poor that you should not be responsible to pay. 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 $370 
copayment per day for days 1-5 for in-network hospital stays. Your cost share starts the day you are admitted 
as an inpatient in a hospital. You pay no cost share for the day you are discharged.  
 
You have been asked to pay a $370 copayment for days 1-2 of the inpatient hospital stay. You have been asked 
to pay a total of $740 ($370 copayment x 2 days = $740). You have not been charged for the day you were 
discharged. This item/service falls within the inpatient hospital care 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 an inpatient hospital stay provided from October 4, 2022, to October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an innerspring mattress (E0271). 
 
You asked the Plan to pre-approve an innerspring mattress. You say that given the enrollee's medical 
comorbidities, as well as complexity of their case, you feel the enrollee is not a good surgical candidate. You 
also say that you deem it medically necessary for the enrollee to have an orthopedic mattress. The Plan denied 
your request. The Plan says the data did not show that the enrollee owns a hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a beneficiary's condition requires a 
replacement innerspring mattress (E0271) it will be covered for a beneficiary owned hospital bed. 
 
 
 
 
 
 We looked at the file and Medicare rules. Specifically, the records do not indicate that the enrollee owns a 
hospital bed. Based on this information, we decided that Medicare rules for coverage of an innerspring mattress 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an innerspring mattress 
(E0271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex insertion of interlaminar/interspinous 
process stabilization/distraction device (22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the enrollee has failed conservative 
approaches to treatment at this time. The Plan denied your request. The Plan says this procedure is 
experimental and investigational as there is insufficient evidence in its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Vertiflex insertion of interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Surgical Cellulose 4in x 8in (2 were charged for but only 1
documented). We had previously decided all other services were not required to be paid.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says the records provided do not support the services billed. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
billing criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Surgical Cellulose
4in x 8in (2 were charged for but only 1 documented). The Plan denied for missing documentation. The
Maximus Physician Reviewer determined that the documentation submitted does not support that Surgical
Cellulose 4in x 8in was billed twice. The Plan requested a reopening, citing an error on the face of the
evidence. The Plan states there is no documentation to support the charge of even 1 Surgical Cellulose 4in x
8in. The medical records show the enrollee the enrollee was a then 69-year-old man with a medical history that
includes aortic stenosis, bioprosthetic aortic valve replacement, ascending aortic aneurysm repair, endocarditis,
hypertension, atrial fibrillation, Guillain-Barre syndrome, prostate cancer, splenic infarct, and gout. The
enrollee was admitted to the hospital on May 24, 2021, with altered mental status. The enrollee was diagnosed
with severe aortic insufficiency, and prosthetic valve endocarditis. The enrollee was scheduled for a re-do
sternotomy, aortic valve replacement, bilateral Pulmonary vein isolation, and left atrial appendage clipping on
June 28, 2021. The enrollee was placed on cardiopulmonary bypass. The Plan is correct in this case. The
clinical documentation does not support the billing of Surgical Cellulose 4in x 8in.
We looked at this physician review, the file and Medicare rules. Based on this information, we decided that
there is insufficient information in the record to determine support the claim as billed. Therefore, we decided
that the Plan does not have to pay for Surgical Cellulose 4in x 8in.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (procedure code 99223) provided to the enrollee on 
February 11, 2022. 
 
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 that Current Procedural Terminology (CPT) code 99223 FS (1 unit) remains 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 
code 99223 is Initial hospital inpatient or observation care, per day, for the evaluation and management of a 
patient, which requires a medically appropriate history and/or examination and high level of medical decision 
making. When using total time on the date of the encounter for code selection, 75 minutes must be met or 
exceeded. 
 
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 supported by the medical records. Our reviewer found that the record supports medical decision 
making of high complexity. There are extensive management options, including additional labs, blood 
transfusion, consultations with neurology and orthopedics, therapy, monitoring, and medication. There is an 
extensive amount of data to review and a high risk of morbidity and mortality due to the postoperative anemia 
and recent hip replacement surgery, along with the patients comorbid conditions. Additionally, the 
documentation supports a comprehensive history and comprehensive exam, which meets the criteria for 
reporting all of the key components for this code. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
initial hospital care (procedure code 99223) provided to the enrollee on February 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device 
(22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the enrollee has suffered from this 
condition for too long and has greatly impacted their quality of life. The enrollee has failed conservative 
approaches to treatment at this time. The Plan denied your request. The Plan says Vertiflex is considered 
experimental and investigational as it is still being studied to determine safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion interspinous spacer device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 28, 2022, by an  
out-of-network provider. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 
require prior authorization. 
 
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 physician's services provided on January 28, 2022, by an  
out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 03, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for home health services. 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 home health services 
provided on August 03, 2022, to August 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit and hospital observation 
services provided from September 21, 2021 to September 23, 2021. 
 
You asked the Plan to pay for the emergency department visit and hospital observation services. The Plan 
denied your request. The Plan says timely filing for non-participating providers is 365 days and the claim in 
dispute exceeded this timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit and hospital observation services was not 
filed until October 26, 2022. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit and hospital observation services provided from September 21, 2021 to September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 9, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says services from non-
participating providers are not covered under open access unless preauthorized. 
 
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 an office visit provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous multi-vitamin therapy. 
 
You asked the Plan to pre-approve intravenous multi-vitamin therapy. You say that intravenous multi-vitamin 
therapy is medically necessary. The Plan denied your request. The Plan says intravenous multi-vitamin therapy 
is not medically necessary. 
 
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 intravenous multi-vitamin therapy. Our 
reviewer says that the requested intravenous multi-vitamin therapy is not considered medically reasonable and 
necessary. Our physician reviewer found that there is no clear evidence that you have a vitamin deficiency to 
justify treatment with vitamins, nor is there a record that you are not able to get enough vitamins orally via 
foods or oral supplementation to justify intravenous vitamin therapy. Therefore, without sufficient support 
made for this request, the intravenous multi-vitamin therapy treatment will be considered not medically 
necessary.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous multi-vitamin therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intravenous multi-vitamin therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the clinical notes describe 
the enrollee's wounds that make it necessary for the 52 gradient pressure pump. The Plan denied your request. 
The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no 
failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the combinatorial pharmacogenomic test (81479) provided 
on September 23, 2022. 
 
You asked the Plan to pay for the combinatorial pharmacogenomic test. You say that this testing was medically 
necessary and should be covered. The Plan denied your request. The Plan says the claim for this test did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the combinatorial 
pharmacogenomic test have not been met. Therefore, we decided that the Plan does not have to pay for the 
combinatorial pharmacogenomic test (81479) provided on September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen concentrator (E1390) and portable oxygen 
concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that you are requesting a reversal of the 
denial of oxygen coverage. The enrollee has chronic lung disease and is dependent on oxygen use. The Plan 
denied your request. The Plan says the rental of the current oxygen equipment began on January 11, 2019. The 
60 months 5-year period will end on January 11, 2024. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has oxygen concentrator (E1390) and portable oxygen concentrator (E1392). 
The oxygen concentrator (E1390) and portable oxygen concentrator (E1392) serves the same purpose as the 
requested oxygen equipment. Therefore, we decided that the Plan does not have to pre-approve oxygen 
concentrator (E1390) and portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion indirect decompression system 
coded as 22869 and 22870. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this treatment is medically necessary 
and appropriate for this stage of the enrollee's disease progression. The Plan denied your request. The Plan says 
Vertiflex is considered experimental and unproven as there is insufficient evidence of its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Vertiflex Superion indirect decompression system coded as 22869 and 22870.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service January 30, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 99291. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not payable. 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 93042 billed for date of service January 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) provided on 
December 31, 2020 and January 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as the claim 
was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until October 11, 2022. This means that more 
than one calendar year from the dates of service had passed before a claim was filed. Therefore, we decided 
that the Plan does not have to pay for the subsequent hospital care, per day (99233) provided on December 31, 
2020 and January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and 
segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that please 
provide out of network authorization. There is no other supplier in the geographical area that can provide the 
prescribed equipment. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an 
out-of-network (OON) provider.