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

We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound debridement services provided on February 17, 
2021, billed with 11 units of code 11047. 
 
You asked the Plan to pay for the wound debridement services as billed. You say that the records support that 
payment should be made for the billed number of units. The Plan denied your request. The Plan says the 
number of units billed are over what is allowed. No medical records were submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that for MUEs with an MAI of 3, payment may be 
made for units in excess of the MUE, if there is adequate documentation of medical necessity of correctly 
reported units. 
 
The MUE of code 11047 is 10, and 11 units were billed. Although the appeal letter indicates that medical 
records are attached, it appears that these were not received by the Plan, as they were not included in the case 
file forwarded to Maximus for review. Without records, it cannot be determined that the number of units billed 
are payable. Therefore, we decided that the Plan does not have to pay for the wound debridement services 
provided on February 17, 2021, billed with 11 units of code 11047.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit (99203), ceftriaxone sodium 
injection (J0696), prophylactic, therapeutic, or diagnostic injections (96372 x 2), and the dexamethasone 
sodium phosphate injection (J1100) provided on January 30, 2021. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 
the services provided. 
 
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 
combined in-network and out-of-network medical deductible of $150. This is the amount you have to pay out-
of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the 
deductible amount, you must pay the full cost for most of your covered services.   
 
You have been asked to pay a $116.11 deductible (90.05+ $2.24+ $11.21+ $1.40+ $11.21) for the medical 
services provided, as you had not previously met the yearly deductible. This is the Medicare allowed amount 
for these services provided. 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 deductible for the office visit (99203), 
ceftriaxone sodium injection (J0696), prophylactic, therapeutic, or diagnostic injections (96372 x 2), and the 
dexamethasone sodium phosphate injection (J1100) provided on January 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health occupational therapy visits. 
 
You asked the Plan to pre-approve home health visits. You say that the enrollee has not met goals and is 
debilitated due to a chronic diagnosis. The Plan denied your request. The Plan says the denial of authorization 
for home health occupational therapy is correct. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health visits. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer 
found the enrollee does not have documented skilled home health occupational therapy needs. The enrollee is 
functioning at a level appropriate for a lower level of care. As such, home health occupational therapy services 
are 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 home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on December 3, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed for medical 
necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services 
rendered by an OON provider. 
 
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 office visit (99214) provided on December 3, 
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient evaluation and management (EM) services provided on 
August 15, 2020, and August 17, 2020, by Philip Cooper, NP. 
 
You asked the Plan to pay for the inpatient EM services. You say that these are both payable because the 
billing provider is of a different specialty. The Plan denied your request. The Plan says that it was found that 
this billing is allowed per plan policy, but the case needed to be forwarded to Maximus due to missing the time 
frame to make a decision. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians of different specialties may both be 
paid for providing EM services on the same date to the same patient. 
 
In this case, although the Plan indicated that this was allowed billing, it was not stated that the Plan agreed to 
pay for these services. Per our review, the two providers billing for EM services on August 15, 2020 are of 
different specialties, meaning payment can be made for both services. The Plan did not provide any evidence of 
another provider billing for EM services on the August 17, 2020 date of service. No other denial rationale was 
provided for this date. As such, we find that the rules for coverage for these services on both dates have been 
met. Therefore, we decided that the Plan has to pay for the inpatient evaluation and management (EM) services 
provided on August 15, 2020, and August 17, 2020, by Philip Cooper, NP.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, paclitaxel, carboplatin, and supportive 
therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the services are not medically 
necessary. In this case, the record indicates that the enrollee has a diagnosis of metastatic neuroendocrine 
tumor. The Food and Drug Administration (FDA) has not stated that the requested Keytruda, paclitaxel, 
carboplatin, and supportive therapy are indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drugs in the enrollee's clinical 
situation. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda, paclitaxel, carboplatin, and supportive therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits. 
 
You asked the Plan to pre-approve 10 additional occupational therapy visits. You say that you are sending 
clinicals to support additional occupational therapy visits. The Plan denied your request. The Plan says 
additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional occupational therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the patient has had prior therapy 
and the caregiver has been instructed in safe toilet transfers and a seating system. Our reviewer says that the 
patient does not require ongoing professional skilled 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 10 additional occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
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 the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of you and able to be furnished safely 
and effectively only on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by 
Medicare. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertilfex device 
is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex device placement surgery for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home nutrition therapy provided from March 14, 2021, to 
March 25, 2021. 
 
You asked the Plan to pay for home nutrition therapy. You say that you were advised that this was the 
appropriate code to bill for this charge. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because code S9343 is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that code S9343 is not valid for Medicare purposes 
and is not payable.  
 
We looked at the file and Medicare rules. This code is not valid for Medicare purposes and is not payable. 
Based on this information, we decided that Medicare rules for coverage of home nutrition therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home nutrition therapy provided from 
March 14, 2021, to March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injections and 
related services provided on April 14, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injections and related services. You 
say that the services provided were medically necessary. The Plan denied your request. The Plan says these 
services were not referred or rendered by an in-network provider. 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 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 therapeutic, prophylactic, or diagnostic 
injections and related services provided on April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on June 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you could not find any network dentists that could see you. You also say that you were in pain and 
had to see the first dentist that was available. The Plan denied your request. The Plan says dental services are 
only covered by your plan when they are performed by a participating general dentist. The Plan also says that 
there is no benefit for dental services performed by an OON dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral 
periapical x-ray (D0220) provided on June 28, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a new inpatient admission provided from January 11, 2021, 
through January 13, 2021. 
 
You asked the Plan to pay for a new inpatient admission. You say that a new inpatient admission was 
medically necessary. The Plan denied your request. The Plan says the inpatient readmission was approved as a 
DRG readmission. 
 
The Plan follows Medicare rules. Medicare rules say to deny readmissions under the following circumstances: 
If the readmission was medically unnecessary; if the readmission resulted from a premature discharge from the 
same hospital; or if the readmission was a result of circumvention of PPS by the same hospital. 
 
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 a new inpatient admission. Our reviewer 
says that a new inpatient admission is not medically necessary. Our physician reviewer found that the enrollee 
is a 69-year-old male with a history of bladder cancer with cystoprostatectomy and ileostomy in 2018 
complicated with hydroureter nephrosis requiring a stent replacement every 90 days who was admitted to the 
acute care facility from January 6, 2021, through January 8, 2021 for the treatment of nausea and vomiting. The 
enrollee was treated for sepsis associated with pyelonephritis and acute kidney injury with intravenous (IV) 
antibiotics for 2 days and transitioned to oral antibiotics on discharge home on January 8, 2021 with improved 
condition. The urine culture was positive for Klebsiella pneumoniae. Urology recommended stent replacement 
as scheduled outpatient. On January 10, 2021, the enrollee returned to the same inpatient acute care facility 
with nausea, vomiting and abdominal pain due to persistent sepsis due to pyelonephritis. The enrollee reported 
feeling nauseous on discharge on January 8, 2021. He was admitted and treated with IV antibiotics and IV 
fluids. The culture again grew Klebsiella pneumoniae. The left ureter stent was replaced on January 12, 2021. 
The readmission was the result from a premature discharge from the same hospital. 
 
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 new inpatient admission have not been met. Therefore, we decided that the 
Plan does not have to pay for a new inpatient admission provided from January 11, 2021, through 
January 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan billed for services 
provided on April 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the documentation does not support an additional 
study. 
 
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 looked at the file and the rules. We find that 2 units of CPT code 70450 were billed and paid for by the 
Plan. The records provided do not indicate that additional studies were performed on the date of service at 
issue.  
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan billed 
for services provided on April 23, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the bladder/urothelial tumor marker testing rendered on June 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the diagnosis is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that bladder/urothelial tumor marker testing is 
covered 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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee presented for evaluation of 
worsening microscopic hematuria that occurred multiple times. As the enrollee in this case has worsening 
microscopic hematuria suggesting a potential diagnosis of bladder cancer, the Medicare coverage criteria are 
met and the testing was reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the bladder/urothelial tumor marker testing rendered on June 23, 2021.  
 
The Plan states that Local Coverage Article (LCA) A55029 states that the billed diagnosis code is not 
supported; however, the LCA does not explicitly state that unlisted diagnosis codes do not support medical 
necessity of the testing. 
 
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.