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

 
We decided that the Plan has to waive the copayment for the specialist office visits provided by an in-network 
provider on April 8, 2022, and May 2, 2022. 
 
You asked the Plan to waive the copayment for the office visits. You say that you were not seen or treated for 
either of these office visits. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records showing that you were present for the 
office visits. Therefore, we decided that the Plan has to waive the copayment for the specialist office visits 
provided by an in-network provider on April 8, 2022, and May 2, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says admission to a SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the atezolizumab injection and the drug 
administration provided on August 15, 2022. 
 
You asked the Plan to waive the cost-sharing for the injection and the drug administration. You say that this 
cost-sharing should be lower. 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 each Medicare-covered chemotherapy drug and the administration of that drug. 
 
You have been asked to pay a cost-share of $325 for the injection because the Plan is only holding you 
responsible for this amount, which is less than 20% of the allowed amount. You have also been asked to pay a 
cost-share of $95.33 for the drug administration ($476.68 x .20 = $95.33 rounded down). These items/services 
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 to waive the 
cost-sharing for the atezolizumab injection and drug administration provided on August 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $539 cost share for cataract removal surgery (66984) and an Astigmatism-Correcting Intraocular Lens (A-C IOL) (V2787) provided on May 31, 2022.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says each outpatient surgical service has a $100 copayment and the
A-C IOL is not covered by the Plan or by Medicare. Maximus upheld the Plans denial. After the decision was made, it was decided a more detailed decision was required.
The Plan is correct in this case. The Plan covers all items that Medicare covers. Medicare does not cover an
A-C IOL inserted during cataract surgery. While an A-C IOL may have been appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, the cost share of $339 for code V2787 was applied correctly.
Regarding the remaining $200, the Plan contract clearly states there is a $100 copayment for each outpatient surgical service which can include facility or surgical fees. The Plan has confirmed you were charged $100 for the cataract surgery (code 66984) and $100 for the surgical fees or ORA fees, which is also allowed by your Plan contract.
Therefore, it remains our decision that the Plan does not have to waive or reduce the $539 cost share for cataract removal surgery (66984) and an Astigmatism-Correcting Intraocular Lens (A-C IOL) (V2787) provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 19, 2022, billed 
with codes 81184, 81284, 81400, 81403, 81404, 81405, 81406, 81407 and 81439. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
was ordered by the enrollee's treating physician. The Plan denied your request. The Plan says panel testing 
should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 19, 2022, billed with codes 81184, 81284, 81400, 81403, 81404, 81405, 81406, 81407 and 81439.
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 you were admitted to the hospital after a fall and needed non-surgical treatment of 
facial fractures. You are now medically stable with no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) 
provided on September 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
localized delivery of antimicrobial agents (D4381) provided on September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization 
(codes 37230 and 37231). 
 
You asked the Plan to pre-approve revascularizations. You say that the enrollee is in danger of losing a toe. The 
Plan denied your request. The Plan says these procedures are experimental/investigational. 
 
The Plan follows Medicare rules. Medicare rules state that certain vascular stenting procedures are considered 
experimental. 
 
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 revascularizations. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested revascularization procedures. Our 
physician reviewer found Medicare guidelines state that stenting of the tibial and peroneal arteries for stenosis 
and occlusions is considered experimental and investigational. Therefore, at this time these procedures would 
not be considered medically appropriate and 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 revascularizations have not been met. Therefore, we decided that the Plan does 
not have to pre-approve lower extremity angiography and revascularization (codes 37230 and 37231).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service April 8, 
2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 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 find that CPT code 99153 is a technical component only code. There is a more appropriate code available 
to describe the work component of physician services. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99153 billed for date of service April 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services coded as 90834, 98967, G0470 and 
G2025 provided May 10, 2022, to August 10, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that preauthorization is not required for 
mental health. The Plan denied your request. The Plan says non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services coded 
as 90834, 98967, G0470 and G2025 provided May 10, 2022, to August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 Sensor. 
 You asked the Plan to pre-approve a Freestyle Libre Kit 2 Sensor. You say that the enrollee needs the requested 
item as soon as possible, due to her health condition. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
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. Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the 
information submitted by the supplier or provider must corroborate the documentation in the beneficiary's 
medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. There were no medical records submitted to confirm that Medicare 
coverage criteria have been met. The Plan shows to have made reasonable attempts to obtain medical records. 
The documentation provided does not demonstrate that the enrollee uses insulin with at least three daily 
injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre Kit 2 
Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
Kit 2 Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that you need a wig due to a medical condition where you 
lost all of your hair on the front half of your head. You would like the Plan to cover the requested wig. The 
Plan denied your request. The Plan says the item requested is not covered by Medicare or the Plan. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81161, 
81238, 81407, 81411, 81413, 81414) provided on April 16, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that the referring 
provider determined that this test was medically necessary. The Plan denied your request. The Plan says 
Medicare denies coverage for all cardiovascular risk assessment panels for enrollees with suspected or 
documented cardiovascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is denied for all cardiovascular risk 
assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cardiac risk assessment genetic screening testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81161, 81238, 81407, 
81411, 81413, 81414) provided on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable under pads (A4554) and an adult sized 
disposable incontinence product (T4524). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the requested items because 
you have frequent urination. You must take water pills and blood pressure medications that cause you to 
constantly urinate. The Plan denied your request. The Plan says the requested supplies are not a covered benefit 
with your Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable under pads (A4554) 
and an adult sized disposable incontinence product (T4524).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D02720) provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 28, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D02720) provided on August 30, 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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can receive the care they need in another setting. 
 
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 enrollee does not have any active medical comorbidities The enrollees needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 lab services (83520) provided on May 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was necessary and should be paid. 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, for 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 (83520) provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength, lightweight wheelchair (K0004), 
elevating leg rests (E0195) and an anti-tipping device (E0971). 
 
You asked the Plan to pre-approve a lightweight wheelchair and accessories. You say that you have a transport 
wheelchair for when you go out. You also say you need a wheelchair for your home so you can get around on 
your own. The Plan denied your request. The Plan says Medicare allows purchasing of medical equipment once 
every five years. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you received a transport wheelchair on December 27, 2022. The records show that 
Medicare allows purchasing of medical equipment once every five years. You have not owned your current 
equipment for more than five years. Therefore, we decided that the Plan does not have to pre-approve a high 
strength, lightweight wheelchair (K0004), elevating leg rests (E0195) and an anti-tipping device (E0971).