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

 
We decided that the Plan does not have to pre-approve a breast lift or mastopexy. 
 
You asked the Plan to pre-approve a breast lift. You say that you would like to proceed with the appeal. You 
also say that you understand that this will not be covered. The Plan denied your request. The Plan says the 
requested procedure is not medically necessary. 
 
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a breast lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
breast lift or mastopexy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen. 
 
You asked the Plan to pre-approve the portable oxygen. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the records indicate your arterial O2 
saturation is 98% on breathing room air. 
 
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 portable oxygen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are submitting records for review. The Plan 
denied your request. The Plan says is not a network provider with the Plan, and the services were not referred 
by a network provider or rendered in an in-network facility. The Plan also says that these services were not 
approved in advance. 
 
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 an office visit provided on June 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation and diagnostic tests 
provided on April 13, 2022, by an OON provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation and diagnostic tests. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 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 psychiatric diagnostic evaluation and diagnostic 
tests provided on April 13, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you do not require frequent self-adjustment of insulin dosage based on 
the blood glucose testing results. 
 
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 the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) and 
supplies.
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 the enrollee is stable and is ready for a 
transfer to an LTACH for continuation of treatment for their complex medical conditions. You say that the 
enrollee's needs are too complex for a skilled nursing facility. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee's needs can be met in current setting. 
 
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 more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ophthalmic biometry provided on June 22, 
2022. 
 
You asked the Plan to waive the deductible for ophthalmic biometry. You say that you should not be 
responsible to pay this. 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. Your 
contract with the Plan says that there is a $250 deductible which applies to diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the diagnostic tests benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 
deductible which applies to diagnostic tests. This cost sharing is a contractual obligation that had not been met 
at the time ophthalmological services was received on June 22, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for ophthalmic biometry provided on June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 27134, 27165, 27170, and 27507 billed for March 3, 
2022. 
 
You asked the Plan to pay for codes 27134, 27165, 27170, and 27507. You say that this was medically 
necessary. The Plan denied your request. The Plan says these codes are not supported in the records. 
 
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 27134 is revision of total hip arthroplasty; both 
components, with or without autograft or allograft. The definition of 27165 is revision of total hip arthroplasty; 
both components, with or without autograft or allograft. The definition of 27170 is bone graft, femoral head, 
neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft). The definition of 27507 is open 
treatment of femoral shaft fracture with plate/screws, with or without cerclage. 
 
We asked our coder 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 codes 27134, 27165, 27170, and 27507. Our reviewer says 
that these codes are not supported. Our reviewer found the operative report does not include sufficient 
documentation to confirm both components (femoral and acetabular) was removed and replaced to support 
billing 27134. The operative report also does not include documentation of an intertrochanteric or 
subtrochanteric osteotomy as described by 27165. It does not describe bone grafting through a separate incision 
as the primary procedure, and therefore 27170 would not be reported separately. The operative report does not 
include sufficient documentation to confirm an open treatment of femoral shaft fracture with plate/screws, with 
or without cerclage to support 27507. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 27134, 27165, 27170, and 27507 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 27134, 27165, 27170, and 27507 billed for March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transurethral Waterjet Ablation of the prostate.
You asked the Plan to pre-approve Transurethral Waterjet Ablation of the prostate. You say that Transurethral
Waterjet Ablation of the prostate 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 state that
Maximus applied the incorrect criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Transurethral
Waterjet Ablation of the prostate.
The Maximus Physician Reviewer determined that the requested transurethral waterjet ablation of the prostate
was considered medically reasonable and necessary in this case. The Plan requested a reopen and argued that
one of the qualifying criteria for the requested procedure is a maximum urinary flow rate of less than 15 mL/s
which is measured with a voided volume over 125 cc. The Plan states these criteria are not met.
Review of the medical records show the enrollee is a 77-year-old man with benign prostatic hypertrophy with
urinary obstruction. The urology notes that the Uroflow peak flow was 12.3 cc/sec, with a voided volume of
95.3 cc, and a PVR of 9 cc. The Plan is correct in this case. The documentation does not support that the
coverage criteria for Transurethral Waterjet Ablation of the prostate, as established by LCD L38726, were met
in this case, as the voided volume was not greater than 125 cc.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Transurethral Waterjet Ablation of the prostate have not been met. Therefore,
we decided that the Plan does not have to pre-approve Transurethral Waterjet Ablation of the prostate.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for pelvic ultrasound provided on August 1, 
2022. 
 
You asked the Plan to waive the cost share for pelvic ultrasound. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $750 
deductible for outpatient diagnostic tests and therapeutic services and supplies. The total amount of these 
ultrasounds totals $434.27. You have not maxed out the $750 deductible.   
 
You have been asked to pay a $750 deductible for pelvic ultrasound. This item/service 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 cost share for pelvic ultrasound provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you have no documentation or 
diagnosis to support an out-of-network referral. You also ask for a recommendation for an in-network provider. 
The Plan denied your request. The Plan says there are available participating/contracted provided within the 
allowable distance who can provide the specific service requested. 
 
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 specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF will provide better care. The Plan denied 
your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
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 December 
22, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment of this code. 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 December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
1, 2021, to July 4, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 is 
a valid diagnosis for this encounter. The Plan denied your request. The Plan says the determination to remove 
principal diagnosis A41.9 (Sepsis unspecified organism) is upheld. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 and diagnosis code A41.9. 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 the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the review has determined that the records did not support the use of diagnosis 
code A41.9 - sepsis, unspecified organism - in this case. The records did not support reporting DRG 871 
(SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC) in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 1, 2021, to July 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing or therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition. The enrollee's care needs can, as a practical matter, be provided at a lower level of a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a screening mammogram and a screening 
digital breast tomosynthesis provided on November 24, 2021. 
 
You asked the Plan to waive the coinsurance for a screening mammogram and a screening digital breast 
tomosynthesis. You say that you were not aware that the provider was out-of-network. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 30% 
coinsurance for out-of-network mammograms.  
 
 You have been asked to pay $48.40 for a screening mammogram. This amount is less than the standard cost 
sharing. You have also been asked to pay $19.45 for a screening digital breast tomosynthesis. This amount is 
less than the standard cost sharing. The total you owe is $67.85 ($48.40 + $19.45 = $67.85).  These 
items/services fall within the mammograms 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 a screening mammogram and a screening digital breast tomosynthesis provided on November 24, 2021.