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

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2022, billed with 
codes 81404 and 81406. 
 
You asked the Plan to pay for the genetic testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this is noncovered cardiovascular screening testing. 
 
The Plan must follow Medicare rules. Medicare 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 testing is 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 have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 20, 2022, billed with codes 81404 and 81406.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on February 
16, 2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that you would like the Plan to pay for 
the services. The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $300 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the lab services were received on February 
16, 2022. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services 
provided on February 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room (ER) visit and 
inpatient hospital care provided from January 3, 2022, to January 5, 2022. 
 
You asked the Plan to waive the copayments for the ER visit and inpatient care. You say that you were only 
under observation for your stay. 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 $90 
copayment per visit for emergency care. This copayment is not waived if admitted to inpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay $210 per day for days 1-6 for each inpatient admission. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. You have also been asked to pay $210 per day for the first 2 days of inpatient care, for a total 
of $420. The inpatient care falls within the Inpatient Hospital Care benefit category. The total for all services is 
$510. 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 copayments for an emergency room (ER) visit and inpatient 
hospital care provided from January 3, 2022, to January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. You 
have been receiving stockings for at least 5 years. You need these stockings to keep your legs from expanding 
more than they are. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does 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 A6549.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Keytruda for the enrollee.
You asked the Plan to provide coverage for Keytruda. You say that this drug 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 Keytruda
(Pembrolizumab). The Maximus Physician Reviewer determined that Keytruda was medically necessary for
the enrollee in this case. The reviewer found that this drug is FDA-approved for the enrollee's
diagnosis, and the compendia reports this drug is safe and effective.
The Plan requested a reopen and stated that Maximus used inappropriate dating regarding the enrollee's
treatment, stating that the enrollee was enrolled on the requested therapy in 2019, when the documentation
states that Keytruda/Alimta therapy was started on November 8, 2018. Maximus stated correctly that the
enrollee had a good response and no progression on the requested drug combination therapy. The Plan notes
that the requested use would be beyond the usual and accepted 24 months of treatment which is not listed as
indicated, supported or recommended in any of the compendia.
Based on review of the medical records, The Plan is correct in this case. The clinical documentation does not
support that the enrollee's disease is a new separate primary. The documentation does not support that this
request for Keytruda was considered safe and effective, and otherwise reasonable and necessary for the enrollee
in this case. The medical literature does not sufficiently support the use of Keytruda beyond two years of
therapy for NSCLC.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to provide coverage for Keytruda for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
28, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that you do not know this doctor and 
did not see them. 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 $5 
copayment for laboratory tests that are not FIT tests.  
 
You have been asked to pay a $5 copayment for the lab services. The lab services 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 laboratory services provided on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical osteogenesis stimulator. 
 
You asked the Plan to pre-approve an electrical osteogenesis stimulator. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an invasive stimulator device 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 an electrical osteogenesis stimulator. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the request does 
not meet NCD criteria, in that it has not been 6 months since the injury, and there has not been a surgical 
approach to repair this fracture. The request is considered not medically reasonable or 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 an electrical osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical osteogenesis stimulator.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 7, 2021. 
 
You asked the Plan to pay for physician's services. You say that this is not a Hospice related claim. The Plan 
denied your request. The Plan says hospice was the primary payer at the time of service and traditional 
Medicare would be responsible for date of service November 7, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on November 1, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on November 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

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 service is not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs or documented skilled therapy needs. The enrollee is not shown to have an acute decline in function. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral x-ray and crown provided on January 17, 
2022, and the resin-based composite provided on February 8, 2022. 
 
You asked the Plan to pay more for the intraoral x-ray, crown, and core buildup. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for the intraoral x-ray and resin-based composite. You are responsible for the $100 deductible 
in addition to the difference between the out-of-network allowance and the total amount billed by an out-of-
network dentist. Therefore, we decided that the Plan does not have to pay more for the intraoral x-ray and 
crown provided on January 17, 2022, and the resin-based composite provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee alignable endoskeletal system. 
 
You asked the Plan to pre-approve the requested services. You say that the ability to change alignment is 
critical as the enrollee's functional level increases. The Plan denied your request. The Plan says the preparatory 
prosthesis is non-alignable. 
 
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 the requested services. Our physician 
reviewer found that it is standard that after a below-the-knee amputation heals a preparatory prefabricated 
prosthesis is provided to help achieve limb maturation and total contact and to avoid multiple socket changes.  
In this case the approved preparatory prosthesis is non-alignable and therefore the requested alignable 
endoskeletal system is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a below knee alignable endoskeletal system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed by an out-of-network (OON) provider on September 9, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 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 for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 $29.84 
Fluoroscopic Guidance $107.47 $53.74 
Genvisc Drug $411.00 $205.50 
Total:  $289.08 
 
You have been asked to pay $289.08, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. The injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug 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 coinsurance for a genvisc joint injection with fluoroscopic guidance performed by an out-of-
network (OON) provider on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on January 11, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you were not informed of the 
copayment at the time of service. 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 $50 
copayment for lab services at an outpatient hospital.  
 
You have been asked to pay a $50 copayment for the lab services. The lab services 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 laboratory services provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for two pairs of routine eyewear 
purchased November 8, 2021. 
 
You asked the Plan to provide additional payment for two pairs of routine eyewear. You say that your coverage 
allows for up to $90 reimbursement when the glasses are purchased out of network. You were expecting to get 
this amount since you did not use this benefit yet for the calendar year. The Plan denied your request. The Plan 
says $90 reimbursement has been issued for one set of glasses. No reimbursement is due for the second pair. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides $90 reimbursement per calendar year for one pair of standard eyeglasses. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that $90 has been 
reimbursed for one pair of eyeglasses purchased November 8, 2021. Based on this information, we decided that 
your eyewear benefit has been exhausted.  Therefore, we decided that the Plan does not have to provide 
additional payment for two pairs of routine eyewear purchased November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure coded 95999 provided on October 14, 2021. 
 
You asked the Plan to pay for the unlisted procedure. You say that the documentation supports CPT 95999 as 
billed. The Plan denied your request. The Plan says the technical report did not include documentation of an 
unlisted neurological or neuromuscular diagnostic procedure so this service cannot be verified. 
 
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 95999 is unlisted neurological or neuromuscular diagnostic procedure. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the unlisted procedure. Our reviewer says that the 
documentation does not support payment for CPT 95999. Our reviewer found the documentation submitted 
was reviewed, and the criteria for coverage have not been met. In this case, the documentation does not support 
an unlisted procedure code. Specifically, the documentation to support an unlisted procedure was not found. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the unlisted procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted procedure coded 95999 provided on October 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
November 7, 2021. 
 
You asked the Plan to pay for an emergency department visit. You say that this patient was not in Hospice on 
this date of service. The Plan denied your request. The Plan says hospice was the primary payer at the time of 
service and traditional Medicare would be responsible for date of service November 7, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 1, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit provided on November 7, 2021.