Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a home ventilator provided on March 25, 
2022. 
 
You asked the Plan to waive the coinsurance for the home ventilator. You say that you were not aware of the 
coinsurance and can no longer afford it. 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 20% 
coinsurance for durable medical equipment (DME), including oxygen equipment.  
 
You have been asked to pay $177.28, which is 20% of the allowed amount for the home ventilator ($886.39 
allowed amount x 20% coinsurance = $177.28). The home ventilator falls within the Durable Medical Equipment (DME) and Related 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 coinsurance 
for a home ventilator provided on March 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE). 
 
You asked the Plan to pre-approve a WCE. You say that this request is due to wanting to screen the small 
intestine due to a personal history of colon cancer. The Plan denied your request. The Plan says this request is 
not medically necessary because the records show the enrollee is not being investigated for gastrointestinal 
bleeding, but rather they are being screened for cancer. 
 
The Plan follows Medicare rules. Medicare rules say that in the absence of occult gastrointestinal bleeding, 
other indications for WCE include the management of celiac disease and of Crohns disease. WCE is indicated 
where an indeterminate type of colitis exists, but where a more specific diagnosis is being sought via small 
bowel evaluation. 
 
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 WCE. Our reviewer says that a WCE 
is not reasonable and necessary for the enrollee. Our physician reviewer found relative to enrollee's family 
history, a capsule endoscopy is indicated in some genetic syndromes associated with heightened risk of 
gastrointestinal tumors. However, the provided record neither supports that the enrollee has tested positive for 
familial adenomatous polyposis, attenuated familial polyposis, nor for MUTYH-associated polyposis 
syndromes nor that they have been found to meet Spigelman stages III or IV. Our reviewer also found that the 
criteria are not supported as met per provided records for WCE in enrollee at this time, nor per their stated 
clinical status as documented at the July 8, 2022, office visit.  
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 WCE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a wireless capsule endoscopy (WCE).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), additional 
intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided on June 7, 2022, or pay more for the 
mandibular partial denture (D5212), and immediate maxillary denture (D5221) provided on June 14, 2022. 
 
  You asked the Plan to pay for the comprehensive oral evaluation, additional intraoral periapical x-ray, and 
panoramic x-ray, and to pay more for the mandibular partial denture, and immediate maxillary denture. You 
say that you were advised by a Plan representative that you would not have to pay anything out of pocket for 
these services. You also say that you are on a fixed income, and cannot afford to pay the full price out of 
pocket. The Plan denied your request. The Plan says your benefits for the comprehensive oral evaluation, 
additional intraoral periapical x-ray, and panoramic x-ray have already been exhausted. The Plan also says that 
you are responsible for a 50% coinsurance for partial dentures, and you will not receive a further 
reimbursement for these services. 
 
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 benefits for the comprehensive oral evaluation, additional intraoral periapical x-ray, and panoramic 
x-ray were exhausted on dates of service March 2, 2022, and June 7, 2022. The contract also clearly states that 
you are responsible for a 50% coinsurance for each partial denture rendered by an in-network provider. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), 
additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided on June 7, 2022, or pay 
more for the mandibular partial denture (D5212), and immediate maxillary denture (D5221) provided on June 
14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69210 billed for date of service December 3, 
2021. 
 
You asked the Plan to pay for procedure code 69210. You say that code 69210 should not be considered global 
to 99214 as both of these line items are separate and distinctly identifiable from each other. You say that this 
code was deemed medically necessary by the provider at the time of service and should be reconsidered for 
coverage. The Plan denied your request. The Plan says there are no modifiers allowed with this code pair. 
  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 69210 
is a column II code to column I code 92557 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 69210 billed for date of service December 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Biogennix Agilon Allograft. 
 
You asked the Plan to pre-approve allograft. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this procedure is experimental/investigational. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited large-scale, long-term, peer-reviewed literature that shows this to be a safe and 
effective treatment for the enrollee's condition. There is no compelling rationale or extenuating circumstance 
noted to support the medical necessity of this request as an exception to guidelines. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Biogennix Agilon Allograft.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home healthcare services provided from December 30, 2021, to 
January 28, 2022. 
 
You asked the Plan to pay for the home healthcare services. The Plan denied your request. The Plan says that 
the provider did not bill as required by Medicare coding regulations. 
 
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. Specifically, the documentation submitted does not include any evidence to 
support why this claim was denied. The file includes a Request for Anticipated Payment (RAP) and there is no 
indication of a discrepancy between the dates of service at issue. The Plan has not clearly stated why these 
claims are not valid. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, 
the Plans denial is not substantiated so we must find in your favor. Therefore, we decided that the Plan has to 
pay for the home healthcare services provided from December 30, 2021, to January 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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 use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and skilled 
nursing services (G0299). 
 You asked the Plan to pre-approve HHA services and skilled nursing services. The Plan denied your request. 
The Plan says you do not meet the guidelines for the requested service which does not appear medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 HHA services and skilled nursing 
services. Our reviewer says that the requested HHA services are not shown to be medically necessary or 
reasonable. Our physician reviewer found you do not have documented skilled needs. Our reviewer also found 
that there is no documentation that HHA services are medically necessary to assist in the treatment of acute 
illness or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA services and skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and skilled 
nursing services (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99152, 99153, and 99053 on April 9, 2021. 
 
You asked the Plan to pay for codes 99152, 99153, and 99053. You say that the enrollee had multiple exams. 
The Plan denied your request. The Plan says these codes are not supported. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. The definition of 99153 is moderate sedation services provided by the same physician or other 
qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, 
requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition 
to code for primary service). The definition of 99053 is service(s) provided between 10:00 PM and 8:00 AM at 
24-hour facility, in addition to basic service. 
 
We find that CPT codes 99152, 99153, and 99053 are not supported in the medical record. Specifically, the 
records do not include documentation of the presence of an independent trained observer to support 99152 and 
99153. Code 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 
99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
codes 99152, 99153, and 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for codes 99152, 99153, and 99053 on April 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Ferrlecit, Infed or Venofer before they will approve the requested drug. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soliris. 
 
You asked the Plan to pre-approve Soliris. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not being prescribed for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Soliris. Our reviewer says that Soliris is 
not medically reasonable and necessary. Soliris is indicated for the treatment of generalized myasthenia gravis 
in adult patients who are anti-acetylcholine receptor antibody positive, which you are not. The use of Soliris is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. Our physician reviewer found that your condition does not meet criteria for coverage of 
Soliris. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Soliris.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary to 
lift you up. The Plan denied your request. The Plan says that this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
a power seat elevation feature (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 provided on March 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Alimta for the enrollee.
You asked the Plan to provide coverage for Alimta. 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 Alimta
(Pemetrexed). The Maximus Physician Reviewer determined that while Pemetrexed is not FDA approved for
the enrollee's diagnosis, its use is supported by one of the major drug compendia or by clinical research that
appears in a CMS-approved medical journal. Due to the rarity of the enrollee's cancer there was a need to rely
on available literature which is case reports. The patient was to be part of a clinical trial with pembrolizumab
that requires insurance coverage of Pemetrexed. Pemetrexed is safe and effective and otherwise reasonable and
necessary for this enrollee. The physician reviewer found that the enrollee's condition meets criteria for
coverage of Pemetrexed. The Plan has requested a re-opening, stating that they did not find the drug's use to be
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved journal.
The medical records show the enrollee is a 79-year-old man with a diagnosis of recurrent metastatic
adenocarcinoma of the salivary gland.
The enrollee presented to oncology on April 19, 2022, for consideration of enrollment in a clinical trial
investigating Pembrolizumab and Pemetrexed for the treatment of recurrent or metastatic salivary cancer.
The Plan is correct in this case. The requested use of Alimta is not FDA-approved for the enrollee's diagnosis.
The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS approved
medical journal. The documentation does not support that the requested drug was reasonably
expected to be safe and effective and otherwise reasonable and necessary for the enrollee in this case.
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 drug have not been met. Therefore, we decided that the Plan does
not have to provide coverage for Alimta for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 25, 2021, billed with 
codes 81105, 81225, 81226, 81230, 81240, 81241, 81291 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare rules. 
 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 
June 25, 2021, billed with codes 81105, 81225, 81226, 81230, 81240, 81241, 81291 and 81479.