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

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an implantable loop recorder. 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 pre-approve an implantable loop recorder. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that while the enrollee has a history of sick sinus syndrome and atrial 
fibrillation/flutter, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke, or any other apparent indication for an ILR. There is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollees 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the enrollee wishes to have this treatment 
and it is covered under Medicare. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because the record does not show why proton beam radiation therapy is considered the 
treatment of choice. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found any potential benefit or detriment of proton therapy over standard intensity-
modulated radiation therapy (IMRT) is an investigational question. Other treatment approaches are also highly 
effective and well-tolerated. Thus, whether proton therapy affords a benefit over standard approaches for the 
enrollee's condition is an area of investigation. It is unlikely that there would be a potential benefit from proton 
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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim is supported by the medical record. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport wheelchair. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is weak and cannot propel 
a wheelchair. The Plan denied your request. The Plan says criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a transport chair is only covered under certain 
medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the records do not clearly document the enrollee has a mobility limitation that significantly 
impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as 
toileting, feeding, dressing, grooming, and bathing in customary locations in the home, that the mobility 
limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker, or that the use of 
a manual wheelchair will significantly improve her ability to participate in MRADLs, that she will use it on a 
regular basis in the home as required by Medicare rules. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transport wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have waive the coinsurance for the trastuzumab injection or the fosaprepitant 
injection provided on September 9, 2021. 
 
You asked the Plan waive the coinsurance for the trastuzumab injection and the fosaprepitant injection. You 
say that you cannot afford to pay this. The Plan denied your request. The Plan says the coinsurance amounts 
have been applied 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 chemotherapy drugs.  
 
You have been asked to pay $192.71 for the trastuzumab injection and the fosaprepitant injection. The 
trastuzumab injection and the fosaprepitant injection fall within the Medicare Part B Prescription Drugs 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 waive the coinsurance for the trastuzumab injection or the fosaprepitant 
injection provided on September 9, 2021.  
 
Date of Service Amount Billed Amount Allowed 20% coinsurance 
September 9, 2021 $2750.70 $37.86 $7.57 
September 9, 2021 $10,854.10 $925.70 $185.14 
Total  $963.56 $192.71
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on February 8, 2022. 
 
You asked the Plan to pay for critical care services (99291). You say that the documentation supports the 
evaluation and management level of care billed and the code is payable as billed. The Plan denied your request. 
The Plan says the documentation submitted does not support a critical care visit of 30-74 minutes was 
performed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
  We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document 
the time spent on critical care services as required by the CPT code billed. Based on this information, we 
decided that Medicare rules for coverage of critical care services (99291) have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99291) provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hysterectomy and bilateral salpingo-oophorectomy. 
 
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. 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 services are not medically necessary. Our physician reviewer found the enrollee has pelvic pain and gender 
dysphoria. The record provided is insufficient to determine the medical necessity of the requested procedure for 
pelvic pain. The record provided is insufficient to determine the medical necessity of the requested procedure 
for the treatment of gender dysphoria. The procedures are not reasonable or medically necessary based on the 
submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hysterectomy and bilateral salpingo-oophorectomy.  Local Coverage Article (LCA) A53793 referenced by the Plan is not valid for the state of Wisconsin and was 
not used in the MAXIMUS determination.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $370.28 coinsurance for a trastuzumab injection provided 
on September 2, 2021. 
 
You asked the Plan to waive the $370.28 coinsurance for a trastuzumab injection. You say that you cannot 
afford to pay this. The Plan denied your request. The Plan says this claim has processed 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 a trastuzumab injection.  You have been asked to pay $370.28 for a trastuzumab injection. A trastuzumab injection falls within the 
Medicare Part B prescription drugs 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 $370.28 
coinsurance for a trastuzumab injection provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wrist hand orthosis on March 16, 2022. 
 
You asked the Plan to waive the coinsurance for wrist hand orthosis. You say that you were under the 
impression the office accepted the plan and did not realize they were out-of-network with the plan until the 
second visit. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 50% 
coinsurance of the Medicare-allowed amount for Medicare-covered durable medical equipment out-of-network. 
Covered items include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic 
supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, continuous glucose 
monitors and supplies, speech generating devices, oxygen equipment, nebulizers, and walkers. The provider 
billed in the amount of $63 and the allowed amount is $57.83. $57.83 x 50% = $28.92. Therefore, results in the 
total cost sharing amount of $28.92.   
 
 You have been asked to pay a 50% coinsurance for wrist hand orthosis. Wrist hand orthosis falls within the 
Durable medical equipment (DME) 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 wrist hand orthosis on March 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for physical therapy services performed March 
14, 2022, to March 22, 2022. 
 
You asked the Plan waive the copayment for physical therapy services. You say that you should not be 
responsible for this. The Plan denied your request. The Plan says the cost share has been applied 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 $35 
copayment for physical therapy.  
 
 
 
 
 
 
 You have been asked to pay a $70 copayment for physical therapy services($35x2=$70). Physical therapy 
services fall within the Outpatient Rehabilitation Services 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 
waive the copayment for physical therapy services performed March 14, 2022, to March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) provided on 
May 16, 2022. 
 
You asked the Plan to waive the copayment for the ECG. You say that an ECG should be a zero-dollar copay. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $70 
copayment for any diagnostic procedure at an outpatient hospital.  
 
 
 
 
 
 You have been asked to pay the allowed amount of $54.13, which is less than the $70 copayment for the ECG. 
The ECG 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 copayment for the electrocardiogram (ECG) provided on May 16, 2022.
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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services you are 
requesting do not meet the requirements for approval. 
 
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 is no documentation provided indicating medical necessity for admission to a 
LTACH. 
 
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 an abdominoplasty. 
 
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. Medicare rules say that an abdominoplasty 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you had massive 
weight loss after bariatric surgery and previously underwent a panniculectomy. The record does not document 
skin inflammation (intertrigo) that has not been helped by conservative medical treatment. The services are not 
reasonable or medically necessary at this time. 
 
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 an abdominoplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 16, 
2022. 
  You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment 
for code 71046. 
 
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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service February 16, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve show lift/insert (foot orthotics). 
 
You asked the Plan to pre-approve foot orthotics. You say that you have a limp and will lose balance without 
this item. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve show lift/insert (foot orthotics).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 tests purchased on December 11, 2021, and 
December 13, 2021. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you received a letter from the Plan stating if 
you purchased home tests prior to February 15, 2022, you would be reimbursed. The Plan denied your request. 
The Plan says COVID-19 tests were not covered at the time they were purchased. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 tests are an OTC item. Medicare required coverage for COVID-19 tests beginning April 4, 2022. 
The documentation shows that the Plan did not provide coverage for COVID-19 tests prior to February 15, 
2022, and these tests were purchased before then. Therefore, we decided that the Plan does not have to pay for 
the COVID-19 tests purchased on December 11, 2021, and December 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to lower the $35 copayment for a physical therapy visit on November 
29, 2021. 
 
You asked the Plan to lower the $35 copayment for a physical therapy visit. You say that you are on a limited 
income and can't afford to pay this. The Plan denied your request. The Plan says the copayment has been 
applied 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 $35 
copayment for a physical therapy visit.  
 
You have been asked to pay a $35 copayment for a physical therapy visit. A physical therapy visit falls within 
the Outpatient Rehabilitation Services 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 lower the $35 copayment 
for a physical therapy visit on November 29, 2021.