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

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 
 
 
 
 
 
 We find that procedure code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator rental for an additional 12 
months (E1390). 
 
You asked the Plan to pre-approve an oxygen concentrator rental. You say that you use your equipment when 
needed and it is becoming more often. You also say you need your equipment when you are away from home. 
The Plan denied your request. The Plan says you have been using oxygen since 2018 and it is not clear if you 
need an oxygen system rental or maintenance. After 36 months, your vendor is required to provide the contents 
and service for months 37-60. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen equipment is limited to 36 months of 
rental.  
 
We looked at the file and Medicare rules. The records show you have been using oxygen since 2018, therefore, 
you will need to contact the vendor for continued use of the requested items for months 37-60. Based on this 
information, we decided that Medicare rules for coverage of an oxygen concentrator rental have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator rental for an 
additional 12 months (E1390).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computerized tomography (CT) scan on 
May 02, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want to appeal the amount being 
charged. 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 $275 
copayment for advanced imaging services at outpatient hospital. Covered services include but are not limited to 
other outpatient diagnostic tests. 
 
You have been asked to pay a $275 copayment for CT scan. CT scans fall 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 
computerized tomography (CT) scan on May 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that you need the help of relatives to get around 
the house. The walking cane does not give you support. You need the scooter as soon as possible. The Plan 
denied your request. The Plan says the records do not show that the enrollee meets the criteria for the requested 
power operated vehicle. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The records 
show that you are ambulatory and uses a walker. This means that Medicare rules for coverage of a PMD have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the power operated vehicle, 
group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that this 
is an appropriate procedure for your back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental for low back pain. Our physician reviewer found that your condition does not meet 
criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0481) provided on June 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service is supported in 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, 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 (G0481) provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for wound care provided by an
outpatient hospital provided on August 6, 2021, and September 3, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the Plan
contract. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested
a reopen and submitted additional information.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay $350 copayment for each
outpatient hospital service. In this case, the facility is charging you less than the normal copayment.
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 share charged for wound care provided by an outpatient
hospital provided on August 6, 2021, and September 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ferric carboxymaltose (J1439). 
 
You asked the Plan to pre-approve ferric carboxymaltose. You say that you have tried other treatments and 
medications that did not work for you. You also say that this is the one your doctor requested for you. The Plan denied your request. The Plan says you have not tried and failed at least 2 of the preferred drugs, Venofer, 
Ferrlecit, Sodium ferric gluconate and Infed. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 ferric carboxymaltose. Our reviewer 
says that the step therapy criteria have not been met. Our physician reviewer found the provided documentation 
does not indicate that you have tried and failed at least 2 of the preferred drugs. The reviewer found that there 
is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects 
for you. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ferric carboxymaltose have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ferric carboxymaltose (J1439).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services provided on September 19, 2021. 
 
You asked the Plan to pay for emergency room services. The Plan denied your request. The Plan says that the 
Plan failed to provide a level 1 decision timely. 
 
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 has not provided the rules for the claim denial. Therefore, we decided 
that the Plan has to pay for emergency room services provided on September 19, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 29, 2022, by an out- 
OON provider. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration. You say 
that the enrollee was prescribed medications in which drug testing is needed to monitor possible opioid abuse. 
The Plan denied your request. The Plan says the out-of-network services were not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 29, 2022, 
by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on February 
18, 2022, by an OON provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the provider saw the 
enrollee in a facility and the facility should have received the prior authorization. The Plan denied your request. 
The Plan says the out-of-network services were not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a subsequent nursing facility care visit provided 
on February 18, 2022, by an OON provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the thorax (71250). 
 
You asked the Plan to pre-approve a CT scan of the thorax. The Plan denied your request. The Plan says that 
this request does not meet criteria for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the thorax. Our reviewer 
says that a CT scan of the thorax is reasonable and necessary. Our physician reviewer found the enrollee has 
persistent left anterior chest wall pain. The rib series of August 3, 2022 was negative. Our reviewer found that 
pain has persisted. Our physician reviewer also found that the request for a CT of the chest is appropriate, as 
plain x-rays are not particularly sensitive for rib fractures. 
 
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 CT scan of the thorax have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) of the thorax (71250).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from October 13, 2021, to 
October 27, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says this provider 
is not supervised by any physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided from 
October 13, 2021, to October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 27, 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 the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen. The Plan states that these services must include an identifier as additional claim documentation. Test providers must receive an identifier specific to the applicable test and submit the test assigned identifier with the claim for reimbursement. The claim submitted does not have a unique test identifier and cannot be paid as billed.
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, this claim cannot be paid due to the omission of the required identifier.
Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies (K0554, K0553). 
 
You asked the Plan to pre-approve Freestyle Libre 2 CGM and supplies. You say that you are requesting a 
continuous glucose monitoring device so you could be more efficient in controlling your sugar. The Plan 
denied your request. The Plan says the records provided do not show that the enrollee meets the criteria. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of Freestyle Libre 2 CGM and supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 continuous glucose 
monitor (CGM) and supplies (K0554, K0553).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the medically necessary 
services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
September 30, 2021.