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

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided on April 21, 2022, to 
June 30, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you cannot afford this charge. 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 20% 
coinsurance for Services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for dialysis. This item/service falls within the Services to treat 
kidney disease 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. You have been asked to pay $1,444.77 which is 20% of the allowed amount for the dialysis services. 
Therefore, we decided that the Plan does not have to waive the coinsurance for dialysis provided on April 21, 
2022, to June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that the enrollee is a 67-year-old male with lung cancer and chronic lower extremity 
swelling who was admitted to the acute care hospital with scrotal and leg swelling following recent suturing of 
penis laceration. He was diagnosed with atrial fibrillation and acute respiratory failure requiring high flow 
oxygen and bilevel positive airway pressure, thoracentesis, and amiodarone drip. Recent notes describe the 
patient as responding to current treatment. The patient appears to be more stable and should only require short-
term additional acute care hospital services that can safely be provided at the current facility until more stable 
and appropriate for a lower level of care. The patient does not require services at the LTACH that are not 
already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid stent placement.  
You asked the Plan to pre-approve the requested services. You say that the enrollee could have a stroke. The 
Plan denied your request. The Plan says the enrollee is not at high risk for carotid endarterectomy. 
 
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 requested services. Our physician 
reviewer found that the enrollee has transient ischemic attack and severe carotid artery stenosis. A 
percutaneous carotid artery stenting (PCAS) is requested. There is no evidence to support that the enrollee 
would be at excessive risk for more traditional carotid endarterectomy surgery, as per Medicare guidelines. As 
such, the requested stenting is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a carotid stent placement.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided from April 22, 2021, through 
April 25, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the claim denied for billing issues, but appeal 
review was not completed. 
 
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 denied this claim citing that there was not sufficient information to pay 
these services under the Outpatient Prospective Payment System (OPPS). However, Maximus reviewed the 
billed codes, and these are all payable under the OPPS. Without a valid rationale, we find that the denial of 
payment is not supported. Therefore, we decided that the Plan has to pay for the outpatient hospital services 
provided from April 22, 2021, through April 25, 2021.  
 
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: Favorable

 
We decided that the Plan has to pay for the GTC-Hematology Profile provided on April 12, 2022. 
 
You asked the Plan to pay for the hematology profile. You say that this is a medically necessary test that is 
covered by Medicare. The Plan denied your request. The Plan says that this was denied due to insufficient 
documentation. An appeal review was not completed. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The test rendered in this case has been reviewed by MolDX and 
found to meet Medicare coverage requirements. No other denial rationale was provided by the Plan. Based on 
this information, we decided that Medicare rules for coverage of the hematology profile have been met. 
Therefore, we decided that the Plan has to pay for the GTC-Hematology Profile provided on April 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 that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the request does not 
meet the LCD criteria of 3 months of pain relief. Therefore, the request is deemed not medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee is able to transfer and does not have a high risk of pressure ulcer. The enrollee does not use a catheter 
or ventilator. There is no significant edema per home nursing. The enrollee does not require power tilt nor 
power recline and does not require expandable controller or elevating leg rests. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 heavy duty power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experiemental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of excessive skin and tissue of both arms. 
 
You asked the Plan to pre-approve the removal of excessive skin and tissue of both arms. You say that the 
records provided support the need for the services in dispute. The Plan denied your request. The Plan says the 
requested procedure is considered cosmetic and is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 removal of excessive skin and tissue 
of both arms. Our reviewer says that the criteria for coverage have not been met. Our reviewer found there is 
no documentation that the surgery to remove the excessive skin and tissue of both arms at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the patient. Provided records document 
the skin and tissue of the arms is very bothersome and there have been unspecified rashes and discomfort with 
clothing, but sufficient detail is lacking in the provided medical records to clarify that the surgery is required 
for the prompt repair of an accidental injury or to improve the functioning of a malformed body member. 
 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 removal of excessive skin and tissue of both arms have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the removal of excessive skin and tissue of 
both arms.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns for teeth numbers 8 and 9. 
 
You asked the Plan to pre-approve the dental crowns. You say that the records provided support the need for 
the requested crowns. The Plan denied your request. The Plan says it is not medically necessary to replace the 
cap on tooth number 9. The Plan says that the x-rays sent show that a crown is not needed to fix tooth number 
8. 
 
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. The Plan covers the dental 
crowns when the services are medically necessary and reasonable.  
 
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 dental crowns. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found tooth number 8 does not appear 
to have significant coronal breakdown due to caries or fracture to warrant a crown restoration. Tooth number 9 
has a crown in place that appears to be adequate with no visible recurrent caries or fracture. There was no 
narrative indicating why the current crown needs replacement. The requested crowns are not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental crowns have not been met. Therefore, we decided that the Plan does 
not have to pre-approve dental crowns for teeth numbers 8 and 9.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 14, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistance provided for a knee arthroplasty on June 
16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistance provided for a 
knee arthroplasty on June 16, 2022.
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 July 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are not included 
in the dialysis rate. 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 July 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not to control power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has multiple sclerosis with an impaired gait and numbness. Per neurology, the 
enrollee does not have significant upper body weakness. The enrollee has sufficient upper body strength to 
manage standard switches. Therefore, the request is not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable control system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this is not a bundled charge. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found absent any detailed 
neurological exam and even mention of possible cervical spine pathology the medical necessity of the 
requested cervical spine MRI has not been demonstrated in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom knee brace and related supplies. 
 
You asked the Plan to pre-approve a custom knee brace and related supplies. You say that the records provided 
support the need for the items in dispute. The Plan denied your request. The Plan says the requested items are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that custom knee braces and related supplies are covered 
for certain medical indications.  
 
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 custom knee brace and related 
supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee has not had recent surgery or a recent injury.  The documentation doesnt support that the joint is 
unstable or that there is joint laxity.  The requested knee orthosis is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a custom knee brace and related supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom knee brace and related supplies.