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

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428), 
ground mileage (A0425), and ambulance oxygen and oxygen supplies (A0422) provided on November 16, 
2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation, ground mileage, and ambulance 
oxygen and oxygen supplies. You say that the enrollee needed his catheter to be changed because it was in for 
too long and he could have gotten an infection. You also say that the catheter could only be changed by a 
urologist. The Plan denied your request. The Plan says non-emergent ambulance transportation is not a covered 
benefit. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. Medicare rules 
also says that payment for items and services, such as oxygen, is included in the fee schedule payment. The 
Plan follows the same rules.  
 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 non-emergency ambulance 
transportation, ground mileage, and ambulance oxygen and oxygen supplies. Our reviewer says that the 
documentation does not support that the ambulance transport on November 16, 2021 was medically reasonable 
and necessary for the patient. Our physician reviewer found the documentation does not support that other 
means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this patient. Our reviewer also found that the documentation does not support that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport on November 16, 2021. 
 
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 non-emergency ambulance transportation, ground mileage, and ambulance 
oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
the non-emergency ambulance transportation (A0428), ground mileage (A0425), and ambulance oxygen and 
oxygen supplies (A0422) provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided July 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
 
 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 services 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 lab services (81479) provided July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MTHFR genetic testing rendered on October 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that MTHFR genetic testing is non-covered.  
 
We looked at the file and Medicare rules. The services at issue are MTHFR genetic testing. This testing is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the MTHFR genetic testing 
rendered on October 22, 2021.  
 
 
 
 Local Coverage Determination (LCD) L38394 referenced by the Plan is for the incorrect jurisdiction and was 
not used in the MAXIMUS determination.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on November 
28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the computed tomography (CT) scan rendered on November 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70551) provided January 1, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed share a bundled relationship. 
 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 70551 
has a bundled relationship with code70552. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services (70551) provided January 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on March 19, 
2021. 
 
You asked the Plan to pay for the services. You say that you were having extreme chest pain, and thought you 
were having a heart attack. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 19, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81162) provided April 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
 
 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 laboratory services 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 laboratory services (81162) provided April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
October 30, 2021, to November 2, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you should not be responsible 
since you were originally supposed to stay only a few hours after your procedure. 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 $325 per 
day for days 1-5 and $0 per day for additional days for each inpatient stay.  
 
The file shows that you were in the hospital from October 30, 2021, to November 2, 2021, but there is no 
copayment for the discharge date. Please note that while the stay was not requested, it was provided as a 
medical necessity. Therefore, you have been asked to pay $325 per day for the first 3 days of inpatient care. 
The total for your stay is $975 ($325 copayment x 3 days = $975). The inpatient care 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 inpatient hospital care provided from October 
30, 2021, to November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that you were admitted for overnight 
observation based on your symptoms and medical history. You also say that the service were medically 
necessary. The Plan denied your request. The Plan says the inpatient hospital admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient admission was medically necessary. Our physician reviewer found the provided documentation did not show that at the time of inpatient admission 
the admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an acute inpatient hospital admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 27, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they have 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 laboratory services provided on August 27, 2021, 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. You received skilled care and 
improved; however, your functional improvement had plateaued by 5/6/22 and you did not require any further 
inpatient skilled rehab services. Your function was at or near your prior level of function and you could be 
discharged to a lower level of care for further services. As a practical matter, you did not require any skilled 
services on an inpatient basis, at a SNF level of care as of 5/6/22. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for budesonide. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the drug is not eligible for a tier exception. 
 
The Plan must follow Medicare rules. The rules say that Part B drugs are not eligible for a Part D tier 
exception. 
 
We looked at the file and Medicare rules. The requested drug is a Part B drug and is not eligible for a Part D 
tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for 
budesonide.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder monitor testing (0013M) provided on April 15, 
2021 by an out-of-network (OON) provider. 
 You asked the Plan to pay for CxBladder monitor testing. You say that CxBladder monitor provides actionable 
results that can make a meaningful difference in the diagnosis and treatment of the enrollee. The Plan denied 
your request. The Plan says the services do not meet Medicare criteria as a review of the medical literature and 
clinical practice guidelines does not support the clinical utility of CxBladder. 
 
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 CxBladder monitor testing (0013M) provided on 
April 15, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided from August 5, 2021, through 
December 7, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that  The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 
 
 
 
 
 
 Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided from August 5, 
2021, through December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, tangential biopsies of skin, and the destruction 
of benign lesions other than skin tags provided on October 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, tangential biopsies of skin, and the destruction of benign lesions 
other than skin tags. You say that that patient presented with 3 neoplasms of uncertain behavior located in 
different locations of the body, and a biopsy was performed on each location. The Plan denied your request. 
The Plan says the rendering provider is a non-participating provider, and there is no referring provider involved 
in these services. The Plan also says they did not authorize any services for this provider. 
 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 an office visit, tangential biopsies of skin, and the 
destruction of benign lesions other than skin tags provided on October 19, 2021, by an out-of-network (OON) 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional outpatient physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve the additional PT sessions. You say that due to the severity of the fracture 
the enrollee will only be able to likely reach her right arm to shoulder height. You also say that by continuing 
therapy you will continue to specifically target exercises to improve the enrollee's right shoulder strength, 
neuromuscular control, flexibility, and endurance in order for her to reach her arm to shoulder height. The Plan 
denied your request. The Plan says there is no clinical evidence to support the medical necessity of this 
examination or that the enrollee meets Medicare criteria for continued physical therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 PT sessions. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the additional requested therapy generally is not 
accepted as specific and effective therapy for the patients condition beyond what was approved by the health 
plan. Our reviewer found that the patient has had prior therapy and the documentation does not reveal that the 
patient requires the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The patient's functional level does not require ongoing skilled PT. She is competent in a home 
exercise program. Our physician reviewer also found that the requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the patient's current condition or to prevent or slow further 
deterioration. 
 
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 PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 additional outpatient physical therapy (PT) sessions.
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 this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another 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 was admitted for diabetic ketoacidosis. 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 medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this 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.