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

We decided the Plan does not have to provide coverage for bioimpedance spectroscopy (BIS) for the enrollee.
You asked the Plan to provide coverage for this request. You say that at the time of the appeal, this treatment
was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bioimpedance
spectroscopy (BIS). The Maximus Physician Reviewer determined that BIS for breast cancer-related
lymphedema assessment has become a standard of care for prevention and treatment. The reviewer found that
the highest risk of developing lymphedema is within the first three years of treatment. The reviewer found that
early intervention can limit progression of disease, and high-risk patients should be followed closely in this
period. The reviewer found that the enrollee in this case is suspected to have subclinical lymphedema.
Therefore, the reviewer found that the requested services are reasonable and medically necessary.
The Plan requested a reopen and argued more research is needed to assess the efficacy of bioimpedance
spectroscopy in the efficacy of identify early lymphedema, and states that bioimpedance spectroscopy is not the
standard of care.
The Plan is correct in this case. NCCN Guidelines Version 1.2022 Survivorship: Lymphedema does not
recommend BIS in the management of lymphedema. The evidence in the medical literature and the clinical
documentation in this case are insufficient to support that bioimpedance spectroscopy is medically 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 this request have not been met. Therefore, we decided that the Plan does not
have to provide coverage for bioimpedance spectroscopy (BIS) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the white glass with gold cap for bridge on tooth #'s 28, 31 (D6752 
x10) provided from January 26, 2022, to May 26, 2022. 
 
You asked the Plan to pay for the white glass with gold cap for bridge on tooth #'s 28, 31 (D6752 x10). You 
say that you were unaware that your Plan did not cover out-of-network providers. You say you were not aware 
the provider was out-of-network. The Plan denied your request. The Plan says that the provider was out-of-
network. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit the Explanation of Benefits or claim form showing any 
services received on May 19, 2022, and May 26, 2022. Therefore, we cannot determine if services were 
received and if the services were provided by an out-of-network provider. Therefore, we decided that the Plan 
has to pay for the white glass with gold cap for bridge on tooth #'s 28, 31 (D6752 x10) provided from January 
26, 2022, to May 26, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation (D0150) and the tooth extraction (D7140) to be provided by an Oral Surgeon.

You asked the Plan to pre-approve the consultation (D0150) and the tooth extraction (D7140). You say that you are in excruciating pain and unable to eat. The Plan denied your request. The Plan says the services are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation (D0150) and the tooth extraction (D7140) are not among those covered under this benefit. Specifically, the services are not covered when provided by an Oral Surgeon. Therefore, we decided that the Plan does not have to pre-approve the consultation (D0150) and the tooth extraction (D7140) to be provided by an Oral Surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 9, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this was not a new patient 
visit. 
 
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 99202 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and straightforward medical decision making. When using time for code selection, 15-29 minutes 
of total time is spent on the date of the encounter".  
We find that CPT code 99202 is not supported in the medical record. Specifically, the records show that the 
enrollee was seen by a provider with the same NPI and specialty on December 7, 2021. As this visit was 
provided within the previous 3 years, it is inappropriate to bill a new patient visit for the services provided. 
Based on this information, we decided that Medicare rules for coverage of the visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on June 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional routine transportation. 
 
You asked the Plan to pay for additional routine transportation. You say that the patient requires transportation 
to attend various specialist appointments. The Plan denied your request. The Plan says the patient has 
exhausted their transportation benefit and no extensions are allowed. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pay for additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery. 
 
You asked the Plan to pre-approve bariatric surgery. You say that bariatric surgery is medically necessary. The 
Plan denied your request. The Plan says the requested bariatric procedure is not medically necessary. The 
patient has already had two other bariatric surgical procedures and continues to consume high calorie beverages 
and foods. 
 
The Plan follows Medicare rules. Medicare rules say that Repeat bariatric surgery is generally not reasonable 
and necessary. Claims for more than one bariatric surgical procedure may be submitted for individual 
consideration, and potentially covered when clinical circumstances demonstrate reasonability and necessity (such as replacing a defective device or correcting a complication in a patient who had met medical necessity 
for the original procedure and has achieved acceptable weight loss. 
 
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 bariatric surgery. Our reviewer says 
that the requested bariatric surgery is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has obesity with a body mass index of 35.42.  The record indicates that the enrollee 
has previously had a lap band and a sleeve gastrectomy but has failed these surgical options. The record 
indicates that the enrollee continues to have dietary indiscretions contributing to the inability to further lose 
weight. The record does not indicate that the requested procedure is to replace a defective device or correct a 
complication in a patient who had met medical necessity for the original procedure.  The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bariatric surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that a continuous glucose monitor is 
medically necessary. The Plan denied your request. The Plan says all the required criteria for a continuous 
glucose monitor are not met. The medical records do not show the enrollee uses three or more injections of 
insulin a day to treat diabetes. The enrollee does not perform frequent blood sugar checks to adjust their 
diabetes treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic This device is considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results.  
 
 The documentation indicates that the enrollee does not perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on 
the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and you can safely receive the services you need 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dialysis services identified with claim numbers 181227753, 
183019108, and 183428382 provided from September 1, 2021, to February 28, 2022. 
 
You asked the Plan to pay for the dialysis services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that there was error on the claims that were submitted. 
 
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. Review of the file shows that the Plan states that these claims were denied due to 
"there was error on the claims that were submitted". However, no other documentation/explanation was given 
as to why the claims had an error. The Plan did not substantiate their denial. Therefore, we decided that the 
Plan has to pay for the dialysis services identified with claim numbers 181227753, 183019108, and 183428382 
provided from September 1, 2021, to February 28, 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 that the Plan does not have to pay for procedure code 99100 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repeat epidural steroid injection (62323). 
 
You asked the Plan to pre-approve the repeat epidural steroid injection. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the records do not show that you had at least 50% of 
pain relief for at least three months with the first injection. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the repeat epidural steroid injection. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the records do not indicate a minimum 50% of sustained improvement in pain 
relief. 
 
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 repeat epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the repeat epidural steroid injection (62323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
tooth #18 (D4266). 
 
You asked the Plan to pre-approve guided tissue regeneration - resorbable barrier, per site tooth #18 (D4266). 
The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration - resorbable barrier, per site tooth #18 (D4266).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that given the enrollee's young age and severity of 
osteoporosis, you would prefer to start them on an anabolic agent first, and Evenity is the only option in the 
enrollee's case. The Plan denied your request. The Plan says the request for Evenity for a diagnosis of 
osteoporosis in a male patient is not an FDA-approved or compendia supported indication. 
 
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 Evenity. Our reviewer says that Evenity 
is not reasonable and necessary for the enrollee. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. Our reviewer also found that the elements of the coverage criteria are not satisfied, and the 
requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care for elective back surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says acute 
inpatient hospital care is not medically necessary. The elective back surgery is considered to be an outpatient 
level of care. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found you are scheduled for an elective L4-L5 MIS laminectomy and microdiscectomy. You are medically stable and you have been cleared for the procedure. The surgery is considered 
outpatient. There is no documentation of you requiring complicated wound care. There is no documentation of 
you requiring nursing services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care for elective back surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided on May 6, 2021, billed 
with multiple codes including code 81404. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says this claim was not billed in accordance with 
Medicare rules. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing panel 
provided on May 6, 2021, billed with multiple codes including code 81404.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids through your provider. 
 
You asked the Plan to pre-approve hearing aids through your provider. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not a covered benefit when ordered through a different 
provider other than plan specified provide. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids when provided through plan specified provide. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids through your provider have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hearing aids through your provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 6, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 6, 2022.