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

 
We decided that the Plan does not have to waive the copayment for an EKG provided on September 22, 2021. 
 
You asked the Plan to waive the copayment for an EKG. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay $14.73 for an EKG, which is less than the standard $40 copayment. This 
item/service falls within the outpatient diagnostic tests 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 copayment for an EKG provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve Freestyle Libre 2 CGM sensor. You say that the enrollee has nocturnal 
hypoglycemia, therefore, using the Freestyle Libre 2 to closely monitor blood glucose levels is recommended. 
The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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 Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and administration (90471) provided on May 11, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you were overdue for a Tetanus shot. You say that you 
received this as part of your check-up. You also say that you received a pneumonia shot during your last check-
up and there was no problem. The Plan denied your request. The Plan says the vaccine is not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) and administration (90471) provided on May 11, 2022.  
 
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee's needs can be met at an alternative level of care like 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 that the clinical documentation shows that the enrollee has functional impairments 
and although evaluating therapists recommend intense therapy, there is no documented IRF compliant 
diagnosis or any documented active comorbidities that would require continued inpatient hospitalization for 
close medical monitoring during rehabilitation. 
 
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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided from  
December 20, 2021, to March 10, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 for 
each physical therapy visit.  
 
You have been asked to pay $30 for each physical therapy visit. The total you owe is $240 ($30 x 8= $240). 
This item/service falls within the physical therapy 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 
copayments for physical therapy provided from December 20, 2021, to March 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Dysport (a preparation of botulinum toxin). 
 
You asked the Plan to pre-approve Dysport. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee is responding well to Botox and there is no clarification on the 
request for use of Dysport instead of Botox. 
 
The Plan follows Medicare rules. Medicare rules state that physicians should use evidence-based medicine to 
select the appropriate botulinum toxin and dose regimen for each patients condition. 
 
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 Dysport. Our reviewer says that the 
enrollee does not meet the Medicare criteria for use of Dysport. Our physician reviewer found the request is for 
Dysport to treat migraine headaches. However, the enrollee is responding well to Botox and the documentation 
does not indicate the enrollee has failed Botox. The medical records reveal a plan to continue Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dysport have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Dysport (a preparation of botulinum toxin).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on March 16, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you are appealing the cost-share due to a 
financial hardship. 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 Medicare-covered durable medical equipment and related supplies.  
 
You have been asked to pay a coinsurance of $177.28, which is 20% of the allowed amount for DME ($886.39 
x 20% = $$177.28). This item/service falls within the Medicare-covered durable medical equipment and related 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME provided on March 
16, 2022.  
 Your complaint about experiencing a financial hardship is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on June 24, 2021 to July 16, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary and should 
be covered. The Plan denied your request. The Plan says the plan is not liable for the services. 
 
The Plan must follow Medicare rules. Medicare rules say that when an enrollee begins coverage in a new 
Medicare health plan during an inpatient hospital stay, payment for the stay is made by the plan the enrollee 
was in on the date of admission to the hospital. 
 
We looked at the file and Medicare rules. The enrollee was not enrolled in the plan until July 1, 2021. Based on 
this information, we decided that Medicare rules for coverage of the inpatient care have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient care provided on June 24, 2021 to July 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, bilateral, radiological supervision 
and interpretation and aortography, abdominal, by serialography, radiological supervision and interpretation 
provided to the enrollee on March 21, 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 code cannot be verified. 
 
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 the denied codes is: 
 
CPT 75716: Angiography, extremity, bilateral, radiological supervision and interpretation 
 
CPT 75625: Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the guidelines do not permit the 
separate billing of an angiographic procedure normally part of the revascularization procedure - CPT 37221 - 
and as such the denied code of 75716 is an appropriate denial. In terms of CPT 75625, the billed code is 
intended for supervision and interpretation only and was an inappropriate code as the performed study was 
injection and not serial films.  As such a more appropriate code would have been CPT 75630. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography, extremity, bilateral, radiological supervision and interpretation and aortography, 
abdominal, by serialography, radiological supervision and interpretation provided to the enrollee on March 21, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that your doctor sent a letter explaining 
the medical necessity for additional transportation. The Plan denied your request. The Plan says you have 
already used up all of your transportation benefit of 24 one-way trips in this benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 8, 2021, to July 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan stated that the enrollee was seen in hospital evaluation on July 8 and 9, 2021. The submitted documentation supports 1 (one) unit each of 99223 and 99233, which were previously approved and paid to the billing provider. There are no additional records showing additional services provided to the enrollee by this physician.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the records show the services billed were previously pay. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 8, 2021, to July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gynecology office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like to see the OON provider. The 
Plan denied your request. The Plan says the requested provider is an OON provider, and it was confirmed that 
the in-network provider has available appointments for the enrollee to receive the services they need along with 
an approved authorization. 
 
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 gynecology 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 pay for inpatient hospital services provided on April 28, 2021 to 
May 7, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis G92 (Toxic Encephalopathy) is a valid diagnosis and the patient met criteria for treatment. The Plan 
denied your request. The Plan says the billed diagnosis of G92 (toxic encephalopathy) is not supported in the 
medical record. 
 
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 a diagnosis of G92 (toxic encephalopathy). 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 billed diagnosis of G92 (toxic encephalopathy) is not supported in 
the medical record. Our physician reviewer found the patient is a 73-year-old male who was treated in the 
hospital with intermittent confusion which didn't improve with treatment in the hospital. It was noted that the 
patient had intermittent dizziness and confusion likely from a mild concussion. There was no evidence found in 
the documentation for a toxic event related to their confusion. Therefore, the billed diagnosis of G92 (toxic 
encephalopathy) is not sufficiently supported in the provided medical record.  
 
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 on April 28, 2021 to May 7, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 10, 2021 to 
March 16, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim was billed correctly. The Plan denied your request. The Plan says the billed principal diagnosis of J96.21 
(acute and chronic respiratory failure with hypoxia) is not supported in the medical record. Instead, the 
principal diagnosis should be J44.1 (chronic obstructive pulmonary disease with acute exacerbation), with 
J96.11 (chronic respiratory failure with hypoxia) being a secondary diagnosis. 
 
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 principal diagnosis of J96.21 (acute and chronic 
respiratory failure with hypoxia). 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 billed principal diagnosis of J96.21 
(acute and chronic respiratory failure with hypoxia) is not supported in the medical record. Our physician 
reviewer found the patient is a 72-year-old female with chronic obstructive pulmonary disease (COPD) (on 3 
l/m oxygen at home), who presented to the hospital with progressive dyspnea and hypoxia, resolved with 2L/m 
oxygen via nasal cannula and bronchodilators. Her lungs were clear, and the patient was not in any acute 
distress in the emergency room. Her white blood cell count was normal, kidney functional was normal, chest x-
ray showed no significant changes compared to prior imaging. Therefore, based on the low complexity/severity 
of the presentation without significant hypoxia beyond her baseline, the billed principal diagnosis of J96.21 
(acute and chronic respiratory failure with hypoxia) is not sufficiently supported in the provided medical 
record.  
 
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 on March 10, 2021 to March 16, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme testing provided on February 3, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that only labs, an order form and test results were sent. There is no history, exam or plan for use of test results. Per Medicare and NCCN guidelines, testing may be appropriate when testing will guide treatment in 
relation to specific diagnosis or unclear diagnosis despite other testing. The review has determined that the 
requested testing at issue in this case 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne Heme testing provided on February 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 21, 2022, to April 20, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says an NOA is required to process. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a valid NOA 
is required to processed for payment. A valid NOA was not submitted. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from January 21, 2022, to April 20, 
2022.