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

We decided that the Plan does not have to provide coverage for Tecentriq (Atezolizumab) and Mvasi
(Bevacizumab).
You asked the Plan to provide coverage for Tecentriq (Atezolizumab) and Mvasi (Bevacizumab). You say that
this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria
are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Tecentriq
(Atezolizumab) and Mvasi (Bevacizumab). The Maxus Physician Reviewer determined that the requested
treatment was medically reasonable and necessary in this case. The Plan requested a reopen and argues that the
diagnosis is Child-Pugh Class B cirrhosis and there is an increased risk of death with treatment of Tecentriq
(Atezolizumab) and Mvasi (Bevacizumab).
The Plan states that the landmark study for Tecentriq (Atezolizumab) and Mvasi (Bevacizumab) included
patients with Child-Pugh Class A cirrhosis only. Therefore, Tecentriq (Atezolizumab) and Mvasi
(Bevacizumab) is not medically necessary and is harmful in this case.
The Plan is correct in this case. The use of Tecentriq (Atezolizumab) and Mvasi (Bevacizumab) for the
treatment of unresectable hepatocellular carcinoma in patients with Child-Pugh class B8 liver cirrhosis, is not
supported as medically accepted in the compendia or in published, peer-reviewed medical literature. Medicare
coverage criteria are not 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 Tecentriq (Atezolizumab) and Mvasi (Bevacizumab) have not been met.
Therefore, we decided that the Plan does not have to provide coverage for Tecentriq (Atezolizumab) and Mvasi
(Bevacizumab).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by the out-of-
network (OON) provider on October 20, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the psychotherapy service (90837) rendered by the out-of-network (OON) provider on 
October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and support accessories 
(E2377, E2313, E2311). 
 
You asked the Plan to pre-approve an expandable controller and support accessories. You say that an 
expandable controller is medically necessary equipment for this power wheelchair. The Plan denied your 
request. The Plan says the criteria for the requested expandable controller have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed 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 an expandable controller and support 
accessories. Our reviewer says that the requested expandable controller and related accessories are not 
medically reasonable and necessary. Our physician reviewer found that the requested items exceed your 
medical needs. You do not require a ventilator, or non-proportional input devices (e.g., sip and puff, head array, 
etc.). You do not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., 
control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. You have 3 power options of tilt, recline, and power elevating leg rests but do not need to control the 
power options through a joystick. The records demonstrate that your upper extremity strength and function 
support that you can control any power options through your own switches. 
 
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 expandable controller and support accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and support accessories 
(E2377, E2313, E2311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the wrist for the
enrollee.
You asked the Plan to pre-approve an MRI. You say that an MRI was medically necessary. The Plan denied
your request. The Plan says an MRI is not demonstrated to be necessary. Maximus overturned the Plans denial.
The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an MRI of the
right wrist. The service at issue was not presented to the Maximus Physician Reviewer correctly. The reviewer
determined that the enrollee had undergone carpal tunnel release with no relief, and under physical therapy.
The next step is MRI of the cervical spine which should be approved due to the persistent symptoms and his
history of physical therapy. The Plan requested a re-opening, citing an error on the face of the evidence. The
Plan notes that they received appeals for two services and MRI of the cervical spine, and MRI of the right
wrist. Upon appeal review, the Plan approved the MRI of the cervical spine. The Plan has requested that the
MRI of the wrist be reviewed. The medical records show the enrollee is a 65-year-old man with carpal tunnel
syndrome with neuropathy of his dominant right hand/wrist. Right carpal tunnel release surgery was performed
in June 2021. Therapy for a duration of 8 weeks was ordered. The documentation is insufficient to support that
an MRI of the right wrist is medically reasonable and necessary for the enrollee in this case. There are no
clinical records documenting the enrollee's response to conservative measures, including his symptoms after
completion of therapy. Medicare coverage criteria are not 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 an MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve magnetic resonance imaging (MRI) of the wrist for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits rendered by the out-of-network (OON) 
provider on November 9, 2021 and December 7, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visits rendered by the out-of-network (OON) provider on November 9, 
2021 and December 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen and oxygen supplies provided during an 
ambulance transport on July 12, 2021, billed with code A0422. 
 
You asked the Plan to pay for the ambulance oxygen and supplies. You say that this claim should be paid. The 
Plan denied your request. The Plan says it was decided to pay for this ambulance trip; however, A0422 is not 
payable by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that ambulance payment under Medicare is made 
through the ambulance base rate plus mileage. No other service is separately payable.  
 
We looked at the file and Medicare rules. Payment for the approved codes is payment in full for this ambulance 
trip. Oxygen and supplies are not separately paid. Based on this information, we decided that Medicare rules 
for coverage of the ambulance oxygen and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the oxygen and oxygen supplies provided during an ambulance transport on July 12, 
2021, billed with code A0422.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on November 21, 2021. You asked the Plan to pay for the testing services. You say that the panel detects genomic alterations. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
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 the gene panel was billed with multiple codes. The medical records provided do not show that the 
service billed with the -59 modifier is a distinct procedural service. If a single procedure is performed, only one 
code with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel testing provided on November 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on September 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with 
previous negative prostate biopsy who are being considered for repeat biopsy. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file does not contain documentation of a previous prostate 
biopsy. 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 pay for the ConfirmMDx testing rendered on 
September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on 
January 19, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that these services were necessary, and 
your dental booklet states that fillings and crown repairs are covered. The Plan denied your request. The Plan 
says these services are not covered under your dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. While crown repairs are listed as a covered service, crowns are not 
listed. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core buildup 
(D2950) provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from September 27, 2021, through 
October 25, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says a Licensed 
Professional Counselor is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
September 27, 2021, through October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on 
November 29, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that the provider is listed as in network on 
your denial. You say that a plan representative advised the provider was out of network. You also say that this service should be covered. The Plan denied your request. The Plan says the provider in this case has opted out 
of Medicare. The Plan also says that payment cannot be made for services rendered by a provider that has 
opted out of Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the outpatient hospital services provided 
from December 7, 2020, through December 8, 2020. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 
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 outpatient hospital visit. Additionally, you must pay a $40 copayment 
for Medicare-covered outpatient rehabilitation services.  
 You have been asked to pay $2,923.54 ($2,883.54 + $40) for the outpatient hospital services provided. This 
amount includes the Plans allowed amount of $14,417.71 x 20% coinsurance=$2,883.54 for the Medicare-
covered outpatient hospital visit provided. Additionally, this amount includes a $40 copayment for the 
Medicare-covered outpatient rehabilitation therapy service provided. 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 share for the outpatient hospital services provided from December 7, 2020, through December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided from August 11, 2021, 
through August 15, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the records support the billed services. 
The Plan denied your request. The Plan says payment cannot be made as time spent was not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order for critical care to be reimbursed, for 
each date and encounter entry, the physician's progress note(s) shall document the total time that critical care 
services were provided. 
 
We looked at the file and Medicare rules. No total time was documented in the critical care notes submitted for 
review. Based on this information, we decided that Medicare rules for coverage of the critical care services 
have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services 
provided from August 11, 2021, through August 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation of an anticipated 
complex surgical approach or another active or unstable medical condition which would require inpatient 
treatment and monitoring in the post-procedure period. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee has 
paroxysmal atrial fibrillation and sick sinus syndrome and is undergoing planned non-emergent cardiac 
pacemaker insertion procedure. This request is for inpatient services following the procedure. However, the 
provided documentation did not describe the patient as unstable clinically or at a high risk for complication for 
the procedure to justify this request. There was no indication that the patient would require hospital services 
that would likely cross 2 midnights. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retroperitoneal ultrasound (76770) provided on January 27, 
2022. 
 
You asked the Plan to pay for a retroperitoneal ultrasound. You say that you have provided records to support 
the service billed. The Plan denied your request. The Plan says rules for payment have not been met because 
the CPT code at issue is inclusive to another billed code. 
 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 76770 
is a column II code to column I code 93975. 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 a retroperitoneal ultrasound (76770) provided on January 27, 
2022.