Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and an appliance. You say that the enrollee would 
face obstacles that would impair healing if forced to use any other device because they are a drop shipment 
company. The enrollee performs a return demonstration to ensure that they fully understand how to operate the 
compression pump properly. In some cases, you coordinate with their home care agency to ensure that all who 
are involved with the enrollee's care are trained for a positive outcome that can conceivably lower insurance 
cost in the future. The Plan denied your request. The Plan says the requested OON provider is not contracted in 
the enrollee's network. These services are available 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 16, 2022, billed with 
multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 
April 16, 2022, billed with multiple codes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on January 7, 2022. 
 
You asked the Plan to pay for the surgical pathology services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 88305 is not supported in the medical record. Specifically, this code has a professional 
component/technical component indicator of 1. This service was billed with a place of service 22 (outpatient 
hospital). This means this code is not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the surgical pathology services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical pathology services provided on January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 2, 2022, 
through January 4, 2022. 
 
You asked the Plan to pay for these services. You say that the inpatient hospital care provided was medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on January 2, 2022 with abdominal pain, 
nausea and vomiting. He had missed dialysis on January 1, 2022. He was evaluated with a history and physical 
exam, laboratory studies, electrocardiogram, chest x-ray, and an abdominal pelvic computed tomography (CT) 
scan. He had evidence of bilateral effusions. He was treated with hemodialysis and intravenous medications. 
His condition stabilized and improved and he was medically stable for discharge on January 4, 2022. The 
review has determined that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from January 2, 2022, through January 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has post Covid-19 symptoms. The 
Plan denied your request. The Plan says services are available 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
evaluation and management services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) panel provided to the enrollee on December 20, 2021.
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test that is covered by Medicare. The Plan denied your request. The Plan says that no Unique Test Identifier issued by Moldx is billed on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes, modifiers and in this case an identifier, based on the Medicare LCD guidelines applicable to the service. Medicare requires claims for this type of testing to be billed with a unique test identifier.
We looked at the file and Medicare rules. Based on L35025, this requirement is applicable as the claim shows the lab test was rendered. The LCD indicates all tests billed within this jurisdiction are required to be billed with a "Unique Test Identifier." We find do not find this identifier was billed on the claim. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) panel provided to the enrollee on December 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. 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 all of
the required criteria.
The Plan is correct in this case. 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.
Review of the medical records show the enrollee's rehabilitation needs did not require at least three hours per
day of skilled nursing or skilled therapy services five days per week. The enrollee's ongoing skilled therapy and
nursing needs could have been provided at a lower level of care.
Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility
(IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions of teeth #4, 6, 7, 10, 11, 14, 18, 23, 24, 26, 29, 30, and 31 for the enrollee.
You asked the Plan to pre-approve the extractions. You say that the enrollee needs to have these teeth extracted to be placed on the liver transplant list. The Plan denied your request. The Plan says that this service is not covered by your Plan's benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve extractions of teeth #4, 6, 7, 10, 11, 14, 18, 23, 24, 26, 29, 30, and 31 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to waive the $195 copayment for diagnostic services provided January 31, 2022.
You asked the Plan to waive this copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial administratively for a lack of information in the case file. The Plan requested a reopen and provided the required Explanation of Benefits to support what services were billed and who provided the services on January 31, 2022.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a copayment between $25-$195 for diagnostic radiology service (not including x-rays).
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 $195 copayment for diagnostic services provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124). 
 
You asked the Plan to pre-approve massage therapy. You say that you rather have therapy then get addicted to 
medication. You have had 6 hip replacements and a lumbar spine issue. The Plan denied your request. The Plan 
says the massage therapy is not part of another therapeutic procedure and not a covered benefit with your Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy (97124).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on April 1, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (27096) provided on the same date of services. Based on this information, 
we decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the 
Plan does not have to pay for the drugs (J3490) provided on April 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR/TAVI) 
with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous 
cannulation (33361, 33367). 
 
You asked the Plan to pre-approve transcatheter aortic valve replacement. You say that the enrollee was 
evaluated for symptomatic severe aortic stenosis with peak AV velocity measured at 3.8 m/s by TTE in 
September 2022. The enrollee was admitted with acute heart failure. She has a SAVR with 21 mm mechanical 
valve on 11/03/2022. The Plan denied your request. The Plan says the TAVR procedure is not medically 
necessary because in the intervening time, the enrollee has had a surgical (open heart) valve replacement to 
treat the symptomatic aortic stenosis. Because the TAVR procedure requested is not medically necessary, the 
related inpatient hospital admission is also 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 transcatheter aortic valve replacement. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found at issue is the medical necessity of the requested TAVR in this 
enrollee, who underwent recent SAVR. Guidelines would not support TAVR based on the submitted medical 
records. As a result, at this time the requested TAVR would not be considered medically necessary in this 
enrollee's clinical management based on the submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter aortic valve replacement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR/TAVI) with 
prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation 
(33361, 33367).
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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollees status is stable and improving. The 
enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
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 treatments are not medically necessary at the LTACH level of 
care.  The enrollee has improved medically but continues to require care in the acute hospital.  She can receive 
further care at the current acute care hospital or a lower level of care when deemed appropriate 
 
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 pre-approve a Group 1 power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for a power wheelchair. 
 
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.  
 
The face-to-face examination report submitted in the file shows that the enrollee does not require the features 
of a power wheelchair to participate in mobility-related activities of daily living (MRADLs) at home. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 1 power wheelchair.
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 are trying to get back home and you have started 
dialysis. The Plan denied your request. The Plan says the request is not medically necessary, the services you 
need can be provided safely in other settings, for example, a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee needs this device to monitor 
his diabetes. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval of the CGM and supplies. 
 
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 use insulin 
with at least three daily injections or 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 therapeutic 
continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that the enrollee's pain is getting worse and 
the enrollee is getting dysfunctional. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for a spinal cord stimulators. 
 
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered for certain 
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 spinal cord stimulator. Our reviewer says that the enrollee does not meet the criteria for a spinal cord stimulator. Our physician reviewer found the 
enrollee does not have an evidence-based indication for a spinal cord stimulator and has not had a surgical 
consultation. This is not medically reasonable or 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a spinal cord stimulator.