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

 
We decided that the Plan does not have to waive the copayment for the advance care planning provided on 
August 19, 2022. 
 
You asked the Plan to waive the copayment for advance care planning. You say that you did a proxy at the 
office for a routine physical and you were not aware that you would be charged a copayment for the service. 
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 $10 
copayment for PCP visit.  
 
 You have been asked to pay $10 for advance care planning. This item/service falls within the PCP visit 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 advance care planning provided on August 
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (TFESIs) 
(64483, 64484). 
 
You asked the Plan to pre-approve TFESIs. You say that the enrollee reported at least 80% relief for 
approximately one month after their last injection on August 3, 2022. The Plan denied your request. The Plan 
says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 TFESIs. Our reviewer says that the 
TFESIs are not medically necessary. Our physician reviewer found there is no documentation that was 
provided to indicate that the enrollee has experienced at least 50% pain relief for three months. Therefore, the 
reviewer found that the requested TFESIs are 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 TFESIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transforaminal epidural steroid injections (TFESIs) (64483, 64484).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra pen. 
 
You asked the Plan to pre-approve the pen. You say that this is medically necessary for treatment of severe 
persistent asthma with acute exacerbation and has failed other medications. The Plan denied your request. The 
Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fasenra pen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says LTACH was denied as 
not meeting criteria, not medically necessary, and continued acute hospital stay was offered, until the member 
could discharge to a lower level of care, such as a skilled nursing facility. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for ostomy supplies (A4373, A4357) and gloves 
(A4927) provided on June 28, 2022. 
 
You asked the Plan to pay the full cost for ostomy supplies and gloves. You say that these items are medically 
necessary. The Plan denied your request. The Plan says these items 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 durable medical equipment.  
 
You have been asked to pay a 20% coinsurance for ostomy supplies. Ostomy supplies fall within the durable 
medical equipment 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. 
 
The rules also say that for equipment to be covered, it must primarily serve a medical purpose. The gloves at 
issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the 
general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the 
Plan does not have to pay the full cost for ostomy supplies (A4373, A4357) and gloves (A4927) provided on 
June 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of upper extremity 
joint without contrast (73221). 
 
You asked the Plan to pre-approve an MRI of upper extremity joint without contrast. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the request does not meet the Medicare or 
health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of upper extremity joint 
without contrast. Our reviewer says that the requested service is not medically necessary. Our physician 
reviewer found the order for left upper extremity MRI (73221) was an obvious clerical error as the enrollee has 
no upper extremity complaints. The records show obvious indication for MRI of the left lower extremity 
(73721). This is a clerical error and resubmission by the referring physician with the appropriate code should 
be advised so the proper exam for this enrollee can be approved. 
 
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 of upper extremity joint without contrast have not been met. Therefore, 
we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of upper extremity 
joint without contrast (73221).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain 
(70552). 
 
You asked the Plan to pre-approve a brain MRI. The Plan denied your request. The Plan says the guidelines 
require that full work-up and testing be done in a clinical setting before an MRI of the brain can be approved. 
The Plan also says while there is concern expressed that the enrollee is reporting worsening short term 
memory, there were no tests reported that would evaluate whether or not this is present, the change over time, 
or the severity. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 brain MRI. Our reviewer says that a 
brain MRI is not reasonable and necessary for the enrollee. Our physician reviewer found according to the 
requesting physician the enrollee has been told they do not have dementia. There are no notes from the 
neurologist. Our reviewer found that the records indicate the enrollee had an MRI in 2020, but no report is in 
the records. No cognitive testing has been done recently, and a neurology referral has been made but is 
pending. Our physician reviewer also found that without any neurological findings on physical exam, notes 
from neurology workup in 2020, and no objective cognitive testing, the medical necessity of the requested MRI 
of the brain has not been established in the submitted records. 
 
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 brain MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) of the brain (70552).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life 2000 portable ventilator. 
 
You asked the Plan to pre-approve a Life 2000 portable ventilator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 life 2000 portable ventilator. Our 
reviewer says that the documentation does not support that the requested ventilator is medically reasonable or 
necessary. Our physician reviewer found the enrollee has COPD and pulmonary fibrosis.  The Life2000 system 
is not a true ventilator because it is not capable of providing full ventilatory support.  There is insufficient 
evidence of effectiveness in the treatment of either COPD or pulmonary fibrosis. Therefore, the enrollee does 
not meet criteria for the requested device.  
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 Life 2000 portable ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Life 2000 portable ventilator.
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 you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says IRF is not medically 
necessary, and your needs can be met at a lower level of care such as skilled nursing facility (SNF), home 
health or outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on February 3, 
2022, to February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the provided items. You say that you were not told you needed to buy from an 
approved vendor. The Plan denied your request. The Plan says you must purchase equipment through an in-
network provider. 
 
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 file shows that a hospital bed and wheelchair were provided. The providers in this case are not network 
providers with the Plan. The Plan had network providers available who could have provided the items at issue 
in this appeal. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for the durable medical equipment provided on February 3, 2022, to 
February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional facet joint injection level. 
 
You asked the Plan to pre-approve the additional level. You say that this is medically necessary. The Plan 
denied your request. The Plan says the information from the provider does not show why three levels would be 
needed. 
 
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 additional level. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the guidelines put a limit of two levels bilaterally. The request exceeds utilization criteria 
and there is no documentation that explains why a third level must be done at the same 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 the additional level have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional facet joint injection level.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from October 28, 
2021, to November 6, 2021. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient documentation supporting the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
billed DRG is supported. The file does show that the Plan made several attempts to obtain additional 
information, with no success. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services 
provided from October 28, 2021, to November 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (PSG) (95810). 
 
You asked the Plan to pre-approve an attended PSG. You say that this procedure is a requirement for you to 
have gastric bypass surgery. The Plan denied your request. The Plan says this service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Type I PSG is covered when used to aid the 
diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed 
attended in a sleep lab facility. 
 
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 attended PSG. Our reviewer says 
that an attended PSG is not medically necessary. Our physician reviewer found you have snoring, obesity, and 
excessive daytime sleepiness, and OSA is suspected. Our reviewer also found that there is no contraindication 
to a home sleep test, such as severe heart or lung disease. 
 
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 attended PSG have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an attended polysomnography (PSG) (95810).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a wrist endoscopy, ulnar nerve neuroplasty, 
and a tendon sheath incision provided on May 26, 2022. 
 
You asked the Plan to waive the cost share for an endoscopy, neuroplasty, and sheath incision. You say that 
you told the provider and provider's office that you did not want surgery on your elbow, and when you woke up 
from surgery, the provider had done it anyway. 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 there is a $1,000 
deductible which applies to certain items and services. The Plan deductible applies to outpatient surgery. The 
Plan also says that you must pay a $325 copayment for outpatient surgery at an ambulatory surgical center.  
 During the processing of these claims a total of $991.54 was applied to your deductible. The endoscopy, 
neuroplasty, and sheath incision you asked the Plan to waive the cost share for falls within the outpatient 
surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $1,000 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had 
not been met at the time the services were received on May 26, 2022.  
 
You have also been asked to pay a $325 copayment for an endoscopy. This item/service falls within the 
outpatient surgery 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 share for a wrist endoscopy, 
ulnar nerve neuroplasty, and a tendon sheath incision provided on May 26, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with 83789 for date(s) of service May 
17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
83789 for date(s) of service May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says none of the diagnostic requirements for this wheelchair have been met. 
 
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.  
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the enrollee's 
condition does not require use of a group 3 wheelchair. She does not have the medical conditions, risk factors, 
functional impairment or treatment needs that Medicare deems medically necessary indications for a group 3 
wheelchair. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.