Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography guidance for placement of radiation therapy 
fields (code 77014) provided on April 4, 2022. 
 
You asked the Plan to pay for computed tomography guidance for placement of radiation therapy fields. The 
Plan denied your request. The Plan says that according to our records the precertification entity was not 
contacted for precertification. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for computed tomography guidance for 
placement of radiation therapy fields (code 77014) provided on April 4, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Computed Tomography (CT) Scan provided on May 2, 
2022. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
 The record indicates that the services were performed out-of-network. Your contract with the plan states that 
prior authorization is required to receive these services out-of-network. Based on this information, we decided 
that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does 
not have to pay for a Computed Tomography (CT) Scan provided on May 2, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on June 4, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says that 
the member's plan provides coverage for charges that are reasonable and appropriate as determined by us. This 
procedure exceeds the maximum number of services allowed under our guidelines for a single date of service. 
 
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. Specifically, the Plan has not provided a Medicare rule or Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for an emergency department 
visit provided on June 4, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing billed with code G0482 for 
September 8, 2022. 
 
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 procedure code G0482 is 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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation does not 
support that 15-21 drug classes were tested. The records show that nine drug classes were tested. 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 definitive drug testing billed with code G0482 for September 
8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-segmented pneumatic compressor (E0650) non-
segmental pneumatic appliance for use with pneumatic compressor, half arm (E0655) and segmental gradient 
pressure pneumatic appliance, half leg (E0673) provided May 26, 2022, to June 14, 2022.  
You asked the Plan to pay for a pneumatic compression device. You say that you are appealing the request for 
the pneumatic compression device for deep vein thrombosis prophylaxis post shoulder arthroscopy. The Plan 
denied your request. The Plan says a pneumatic Compression Device (PCD)that provides intermittent limb 
compression for the purpose of prevention of venous thromboembolism (which should be billed as E0676) is a 
preventive service and is excluded from coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for non-segmented pneumatic compressor (E0650) non-segmental pneumatic appliance for use with 
pneumatic compressor, half arm (E0655) and segmental gradient pressure pneumatic appliance, half leg 
(E0673) provided May 26, 2022, to June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) and 
supplies (K0553, K0554) provided on March 9, 2022. 
 
You asked the Plan to pay for the CGM and supplies. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as proof of 
delivery was not obtained. 
 
  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no proof of delivery provided and the record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) and supplies 
(K0553, K0554) provided on March 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 2, 2022, to 
February 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 2, 2022, to 
February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the out-of-network continuous positive 
airway pressure (CPAP) equipment provided from August 29, 2022, to September 29, 2022. 
 
You asked the Plan to waive the cost-sharing for the out-of-network continuous positive airway pressure 
(CPAP) equipment. You say that these items should be covered. 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 30% 
coinsurance for out-of-network durable medical equipment, which includes oxygen equipment. 
 
 You have been asked to pay a cost-share of $188.31 for the continuous positive airway pressure (CPAP) 
equipment ($275.11 allowed amount x .30 = $82.53) ($352.60 x .30 = $105.78). These items/services fall 
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 out-of-network continuous positive airway pressure (CPAP) equipment 
provided from August 29, 2022, to September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an electrocardiogram (ECG) and a 
specialist visit provided on October 3, 2022. 
 
You asked the Plan to reduce the copayment for an electrocardiogram (ECG) and a specialist visit. You say that 
you have never paid a separate copayment for an EKG, and it has been considered part of the cardiology exam. 
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 $75 
copayment for all other diagnostic radiology services and a $35 copayment for each specialist visit.   
 
  You have been asked to pay a total copayment of $48.84 for an electrocardiogram (ECG) and a specialist visit. 
This total includes $13.84 for an ECG, which is less than the $75 standard copayment, and a $35 copayment 
for a specialist visit. The ECG falls within the Outpatient Diagnostic Tests benefit category. The specialist visit 
falls within the Physician/Practitioner Services 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 reduce the 
copayment for an electrocardiogram (ECG) and a specialist visit provided on October 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive metabolic panel (80053), thyroid stimulating 
hormone (84443), and complete blood count (85025) provided on August 12, 2022. 
 
You asked the Plan to pay for the comprehensive metabolic panel, thyroid stimulating hormone, and complete 
blood count. The Plan denied your request. The Plan says that payment was made according to the Medicare 
allowable amount. 
 
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. Specifically, the provided documentation does not show that the Plan made any 
payment for these services. No information was provided to support the Plan's decision. Consequently, the Plan 
has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the 
comprehensive metabolic panel (80053), thyroid stimulating hormone (84443), and complete blood count 
(85025) provided on August 12, 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: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on April 1, 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 for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan demonstrated that the claim was billed with diagnosis codes R06.02 and J96.00. However, Medicare guidelines state these codes cannot be billed together. Therefore, payment was denied.
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 codes. In this case, this claim could not be paid as billed due to an issue with the combination of diagnosis codes billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services or pay for the 
self-administered drugs provided from September 15, 2022, to September 18, 2022. 
 
You asked the Plan to waive the copayment for the emergency room services and to pay for the self-
administered drugs. You say that you would like to appeal these services. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. The Plan also says that self-administered drugs are not 
covered by Medicare or the health plan. 
 
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 $90 
copayment for Emergency Care. The rules also say that Medicare Part B generally does not pay for self-
administered drugs. 
 
You have been asked to pay a $90 copayment for the emergency room services. This service falls within the 
Emergency 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. Also, the self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to waive the copayment for the emergency 
room services or pay for the self-administered drugs provided from September 15, 2022, to September 18, 
2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing-four or more 
teeth per quadrant (D4341 x 4) and the resin-based composites-one surface, posterior (D2391 x 3) rendered by 
the out-of-network provider from May 27, 2022, through July 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The cost sharing has been applied correctly to the services provided.  
 
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 if you obtain covered 
services from an out-of-network provider who does not participate with Medicare, you may be billed by the 
out-of-network provider for any charged amount greater than the payment made by the Plan. Enrollees must 
pay a 20% coinsurance for comprehensive dental services rendered by an in-network provider and an 80% 
coinsurance for comprehensive dental services rendered by an out-of-network provider.  
 
You have been asked to pay $146.92 ($49.44 + $48.74 + $48.74) for the dental services rendered by an  
out-of-network provider. This includes the Plans allowed amount of $82.44 x 20% coinsurance= 
$16.48 x 3= $49.44 for the services provided on May 27, 2022. Additionally, this includes the Plans allowed 
amount of $121.87 x 20% coinsurance=$24.37 x 2= $48.74 for the services provided on June 22, 2022 and  
July 22, 2022. These dental services were processed at the in-network benefit level by the Plan. Therefore, your 
cost sharing liability is less than the applicable coinsurance for these services rendered by an out-of-network 
provider. Additionally, you have been asked to pay the difference between the out-of-network providers 
charges and the Plans payment. 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 pay more for the periodontal scaling and root 
planing-four or more teeth per quadrant (D4341 x 4) and the resin-based composites-one surface, posterior 
(D2391 x 3) rendered by the out-of-network provider from May 27, 2022, through July 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a PET scan for initial staging of prostate cancer for the enrollee.
You asked the Plan to provide coverage for a PET scan. You say that the requested PET scan is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare does not cover a PET scan for the initial diagnosis of prostate cancer. Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to provide coverage for a PET scan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bebtelovimab infusion provided on August 03, 2022. 
 
You asked the Plan to pay for Bebtelovimab infusion. You say that you should not have to pay for the billed 
service because your primary care provider (PCP) did not give you a referral. 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 Bebtelovimab infusion 
provided on August 03, 2022.