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

We decided that the Plan does not have to waive the cost-sharing for the outpatient specialist visit, and rabies injections/vaccines received from September 4, 2021, through September 18, 2021.
You asked the Plan to waive the cost-sharing for the outpatient specialist visit and rabies injections/vaccines. You say that it's not fair you are being punished more by having to pay for being attacked by a dog. 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 20% coinsurance for Medicare Part B drugs and a $40 copayment for a specialist visit.
You have been asked to pay a 20% coinsurance for the rabies injections/vaccines and a $40 copayment for the outpatient specialist visit. The rabies injections/vaccines fall within the Medicare Part B drugs and the outpatient specialist visit falls within the specialist visit 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-sharing for the outpatient specialist visit, and rabies injections/vaccines received from September 4, 2021, through September 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the records provided support the need 
for the requested services. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the CardioMEMS device has not been demonstrated in the peer-reviewed literature. 
 
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 a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service November 8, 
2021. 
 You asked the Plan to pay for procedure code 97530. You say that medical records were provided. The Plan 
denied your request. The Plan says payment for code 97530 is bundled into payment for code 82526. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 97530 is a column II code to column I code 82526. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 97530 
billed for date of service November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and trimming of nondystrophic nails. 
 
You asked the Plan to pre-approve an office visit and trimming of nondystrophic nails. You say that the 
requested services are medically necessary as there was a bleeding trauma to your toe from denial of coverage 
of podiatrist care that took some time to control. The Plan denied your request. The Plan says Medicare and the 
Plan do not cover routine foot care. This includes cutting or removing calluses and trimming or cutting nails. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pre-
approve are routine foot care services. Based on this information, we decided that Medicare rules for coverage 
of an office visit and trimming of nondystrophic nails have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an office visit and trimming of nondystrophic nails.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for exploration of spinal fusion (22830) provided to the enrollee on November 24, 2021.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that they agree that the exploration was performed after the plate removal, however, per National Correct Coding Initiative (NCCI) exploration of the spinal field should not be reported separately when performed in the same anatomic area as another spinal procedure. Since the plate was removed from a previous fusion at C4-6 and the bone growth found during exploration is across the C3-C4 disc space code 22830 would not be separately reimbursable due to being performed in the same area. Per NCCI guidelines, exploration of the surgical field is a standard surgical practice. Providers and suppliers shall not report a code describing exploration of a surgical field with another code describing a procedure in that surgical field. For example, code 22830 describes exploration of a spinal fusion. Code 22830 shall not be reported with another procedure of the spine in the same anatomic area. However, if the spinal fusion exploration is performed in a different anatomic area than another spinal procedure, code 22830 may only be reported separately with modifier 59 or XS.
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 and when appropriate the necessary modifiers. In this case, this claim cannot be paid as billed due to the omission of the required modifier. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for exploration of spinal fusion (22830) provided to the enrollee on November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amounts for the specialist visit (99213) and 
Orthovisc injection (J7324) provided on May 27, 2022. 
 
You asked the Plan to waive the cost sharing amounts for the specialist visit and Orthovisc injection. You say 
that you should not have been charged $39.63 because of the insurance you have. 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% of 
the total cost for Medicare-covered drugs and administration, and a $10 copay for each Medicare-covered visit.  
 
 
 You have been asked to pay a 20% coinsurance for the specialist visit and a $10 copayment for the Orthovisc 
injection. These items/services fall within the Medicare Part B prescription drugs benefit category and 
Physician/Practitioner services, including doctors office visits 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 sharing amounts for the specialist visit (99213) and Orthovisc injection (J7324) provided on 
May 27, 2022.
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 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 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 the enrollee was admitted to the hospital for surgical repair of a hip fracture after a 
fall. She is now medically stable with no complex nursing or rehabilitation needs. She does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that the enrollee 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: 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 have a compliant diagnosis and need 
improvement on endurance and strength in order to return home. The Plan denied your request. The Plan says 
you do not meet medical necessity for admission to the IRF. 
 
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 you were admitted to an acute hospital on October 15, 2022, after a fall sustaining 
right hip fracture. There are no complex nursing or rehabilitation needs. While you have a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Your 
rehabilitation needs can be safely met in a lower intensity setting. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled services provided from January 1, 2022 to January 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled services. You say that you would like to appeal the skilled services. 
The Plan denied your request. The Plan says services from non-participating providers are not covered unless 
pre-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 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 skilled services provided from January 1, 2022 
to January 25, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on January 31, 2022, 
and February 2, 2022. 
 
You asked the Plan to waive the copayment for ambulance service. You say that he is hoping to have the 
copayments waived because he could not pay these bills. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $125 copayment for ambulance services.  
 
The enrollee has been asked to pay $125 copayment for each ambulance. This item/service falls within the 
ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance provided on January 31, 2022, and February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a preparatory prosthesis (L5540) for the enrollee.
You asked the Plan to provide coverage for this prosthetic component. You say that this equipment is medically necessary. The Plan denied your request. The Plan says this request is being requested and coded improperly. Maximus overturned the Plans denial stating the equipment was reasonable and necessary. The Plan requested a reopen and stated that the issue was Medicare guidelines state that adjustments of the prosthetic and components are make when fitting he prosthesis to the member as needed 90 days from the date of deliver. These adjustments are included in the reimbursement or payment for the unit and are not separately payable by Medicare and cannot be pre-approved by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. This code involves a component and services provided after the prosthetic is received and used by the enrollee to apply needed adjustments. This is not a separately payable service. Therefore, we decided that the Plan does not have to provide coverage for a preparatory prosthesis (L5540) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a trans-thoracic echocardiogram (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the enrollee has chest pain and is noted to have an early 
systolic murmur. An electrocardiogram (EKG) is necessary for investigation. The Plan denied your request. 
The Plan says the criteria for coverage of this service are not met as the enrollee has not had a change in 
clinical status related to the heart or new signs or symptoms. 
 
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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted records do not show any cardiac signs or symptoms which would support 
carrying out a TTE in this setting. There is no supporting evidence to show the medical necessity of a TTE in 
this enrollee's clinical management. 
 
 
 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a trans-thoracic echocardiogram (TTE) (93306).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 29, 2022.
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 need this level of care. The Plan denied your 
request. The Plan says admission to the IRF was denied as not meeting criteria. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an 
infection of the foot, midfoot amputation, and pneumonia. Medical problems are stable. There are no complex or nursing rehabilitation needs. While you have a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 1, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued rental of a continuous positive airway 
pressure (CPAP). 
 
You asked the Plan to pre-approve continued rental a CPAP. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for continued CPAP use. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a positive airway pressure 
device beyond the first three months of therapy requires the following: 
1. The enrollee has used the machine 70% or more of the nights in a month. 
2. The enrollee has used the machine at least four hours a night. 
3. The enrollee has been seen by your doctor in the last three months for review of the CPAP use and benefits.  
 
We looked at the file and Medicare rules. Review of the file does not include documentation that the enrollee 
used the machine for 70% or more of the nights in a month, used the machine at least four hours per night, or 
that the enrollee was seen by their doctor in the last three months for the review of the CPAP use and benefits. 
Based on this information, we decided that Medicare rules for coverage of continued rental a CPAP have not 
been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a continuous 
positive airway pressure (CPAP).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided September 7, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you would like the Plan to cover this 
service. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on September 7, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided September 7, 2021.