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

We decided that the Plan does not have to reduce the $40 copayment charged for urgent care services provided on August 24, 2021.
You asked the Plan to reduce this cost share. You say that you went to urgent care because your primary doctor was not available, and you should not be overcharged for that. The Plan denied your request. The Plan says this cost share was applied based on the location of the service, the claim submitted by the provider and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay a $40 copayment for urgent care services. Rather than wait for your primary physician to be available you chose to go to urgent care. You have been asked to pay the correct amount based the services rendered and 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 $40 copayment charged for urgent care services provided on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a screening (CTC) scan of the colon.
You asked the Plan to provide coverage for this screening. You say that this service was necessary instead of a traditional colonoscopy. The Plan denied your request. The Plan says this type of scan is not approved for screening purposes. Maximus overturned the Plans denial stating the CTC scan would be beneficial. The Plan requested a reopen and stated that Medicare does not cover these scans for screening purposes.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that CTC scans for colorectal cancer screening remains non-covered. This scan was requested for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a (CTC) scan of the colon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and prophylaxis services (D1110) provided on December 20, 2021.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says on December 20, 2021, the benefits billed had been exhausted. Maximus overturned the Plans denial for a lack of claim information in the file to show these services were previously paid. The Plan requested a reopen and provided the required claim information. The Plan provided documentation to show that you received same dental services on June 15, 2021 (D1110) , June 18, 2021 (D0120 and D1110) and June 30, 2021 (D0150, D0210 and D1110).
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, certain limitations apply. The record shows your benefit for the services provided was exhausted prior to the date of service. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120), and prophylaxis services (D1110) provided on December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a PET scan for the enrollee.
You asked the Plan to provide coverage for a (PET) scan. You say that at the time of the appeal, this PET scan was medically necessary. The Plan denied your request. The Plan says Medicare does not cover a PET scan for the initial staging of prostate cancer. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover a PET scan for the initial stating or prostate cancer. This PET scan was requested for that purpose. Therefore, we decided the Plan does not have to provide coverage for a positron emission tomography (PET) scan for the initial treatment of prostate cancer for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Yescarta CAR-T cell therapy for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that Yescarta is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are 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 Yescarta (Axicabtagene ciloleucel). The Maximus Physician Reviewer determined that Yescarta is medically appropriate for the enrollee, as he had received greater than 2 lines of prior therapy. The Plan requested a reopen and argues that the NCCN guidelines explicitly state for Diffuse Large B-Cell Lymphoma anti-CD19 CAR T-cell therapy after relapse number 2 or greater is recommended if not previously given. The plan also notes that the chart notes indicate that the enrollee suffered severe CAR T-cell related adverse events. The Plan states that the request for CAR-T treatment in the 7th line setting is not based on evidence or guidelines and would be experimental and not medically necessary.
The medical records show the enrollee is a 65-year-old man with a diagnosis of diffuse large B-cell lymphoma. Previous therapy has included R-CHOP, R-GEMOX, and Kymriah CAR-T therapy. There was a partial response at day 30, but the enrollee had progression of disease by 6 months after therapy. The enrollee received an allogenic stem cell transplant on December 27, 2021, however there was progression after day 70 post-transplant. A second CAR-T infusion has been recommended. The Plan is correct in this case. There is insufficient evidence in the medical literature to support a second CAR-T cell therapy. 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 treatment have not been met. Therefore, we decided that the Plan does not have to provide coverage for Yescarta CAR-T cell therapy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been six weeks of provider-directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that more conservative 
measures for low back pain are needed, including physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress echocardiogram. 
 
You asked the Plan to pre-approve a stress echocardiogram. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service at issue 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 a stress echocardiogram. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that your pre-test probability for an abnormal test is low and there is no 
documentation that the electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence 
provided that would support the need for stress echocardiography. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a stress echocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a stress echocardiogram.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing received on November 8, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you cannot afford this bill. The Plan denied your 
request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 testing is only covered when 
the enrollee has a personal history of cancer.  
 
We looked at the file and Medicare rules. Review of the file shows that you do not have a personal history of 
cancer. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing received on 
November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 23, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81335, 
81355, 0031U, 0032U, 0033U, 81407, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 provided on 
March 23, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81335, 
81355, 0031U, 0032U, 0033U, 81407, and 81238.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 17, 2021, to 
December 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 home health services provided on November 17, 
2021, to December 29, 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 diabetic supplies provided on January 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for diabetic supplies. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 diabetic supplies provided on January 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 1, 2021, to March 31, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
1, 2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on April 26, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 the injection services provided on April 26, 2022 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig received on February 15, 2022. 
 
You asked the Plan to pay for the wig. You say that you were told that the Plan would pay 80% of the cost. The 
Plan denied your request. The Plan says the item received is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig received on 
February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are 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 and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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 CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient hospital visit on March 23, 
2022. 
 
You asked the Plan to waive the coinsurance for an outpatient hospital visit. You say that you should not be 
responsible for this cost share. The Plan denied your request. The Plan says the claim was process 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 40% 
coinsurance for an out-of-network outpatient hospital visit.  
 
You have been asked to pay $46.96 for an outpatient hospital visit. An outpatient hospital visit falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and 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 coinsurance for an outpatient hospital visit on March 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 4, 
2022, to January 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient mental health services provided on 
January 4, 2022, to January 18, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that the service was medically necessary. The 
Plan denied your request. The Plan says payment for code 71250 is bundled into payment for code 71275. 
 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 71250 
is a column II code to column I code 71275. 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 procedure code 71250 billed for date of service March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a micro slide consultation (88321) provided on May 19, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the micro slide consultation. 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. 
 
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 a micro slide consultation (88321) provided on 
May 19, 2022 by an out-of-network (OON) provider.