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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is rapidly declining. The 
Plan denied your request. The Plan says the requested settings can be provided by another device. 
 
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 the requested services. Our physician 
reviewer found that the enrollee has amyotrophic lateral sclerosis. The provided documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with advanced volume-assured pressure support capability (AVAPS).  
The plan has indicated coverage for such a device is available upon request. The elements of the coverage 
criteria are not satisfied. Therefore, the requested service cannot be recommended. 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 home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on October 18, 2021. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you do not 
agree with the cost sharing amount. 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 $225 
copayment for Medicare-covered advanced radiology services, which includes magnetic resonance imaging 
(MRI). 
 
You have been asked to pay a $225 copayment for magnetic resonance imaging (MRI). This item/service falls 
within the Medicare-covered advanced radiology services, which includes magnetic resonance imaging (MRI) 
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 magnetic resonance imaging 
(MRI) provided on October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal fusion and decompression surgery coded as 
63047, 22633, 22853, 22840, 20930, 20936, and 63048. 
 
You asked the Plan to pre-approve the spinal surgery. You say that it is medically necessary to perform the 
surgical procedure that you have recommended for the enrollee. The Plan denied your request. The Plan says 
the records do not show that the enrollee meets the Plan criteria, and the surgery is not medically necessary. 
 
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 spinal surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the imaging studies do not show severe stenosis or instability at any level. The 
surgery not 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 the spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal fusion and decompression surgery coded as 63047, 22633, 22853, 22840, 
20930, 20936, and 63048.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that IMRT 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being offered palliative 
radiation to the pelvis. IMRT for bone metastases is uncommonly needed for the palliative treatment. For this 
case, while there are planning records, there is no plausible dosimetric rationale for IMRT. The number of 
fractions is not provided or is not clearly legible; though, if it is 20 fractions, that is also not standard of care. 
The criteria for coverage are not met and the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve computerized knee and advanced foot feature. 
 
You asked the Plan to pre-approve computerized knee and advanced foot feature. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says that the requested items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that additions to prosthetic legs are only covered for 
certain indications. 
 
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 computerized knee and advanced foot 
feature. Our reviewer says that the documentation supports that the requested computerized knee and advanced 
foot feature are medically reasonable and necessary. Our physician reviewer found the enrollee has a medical 
history of carpal tunnel syndrome, lupus, and factor V Leiden disorder. The enrollee currently has a prosthesis 
with a socket which is no longer fitting due to residual limb volume changes, and he requires replacement of 
his prosthetic components. A clinical progress note indicated the enrollee has a left sided transfemoral 
amputation with some skin breakdown of the residual limb. A prosthetic note dated June 14, 2022, indicated 
that the enrollees liner is loose, and the enrollee is currently using 8 ply of socks. 
 
The enrollee requires a transfemoral prosthesis for mobility and performing daily activities. The enrollees 
current prosthetic socket is no longer fitting despite modifications due to residual limb changes. The 
documentation provided does support the use of the requested prosthesis with K3 components. There is 
documentation from the enrollees physician and prosthetist that the enrollee can function at K3 level. The 
enrollee is noted to walk on uneven terrain and negotiate flights of stairs while carrying objects. There is no 
indication of a cardiac or respiratory condition that would not allow the enrollee to function at the K3 level. A 
functional measurement tool was used to calculate the enrollees ability to use a microprocessor knee. 
Therefore, the requested replacement transfemoral prosthesis with K3 components, specifically a 
microprocessor knee and advanced foot/ankle system is 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 computerized knee and advanced foot feature have been met. Therefore, we 
decided that the Plan has to pre-approve computerized knee and advanced foot feature.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for intravitreal injection and injection of drug 
provided on September 26, 2022. 
 
You asked the Plan to waive the cost share for intravitreal injection and injection of drug. You say that you do 
not understand why the provider is showing as non-participating and you would like the claim to be 
reprocessed and paid. 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 50% out-
of-network coinsurance at specialist office and $65 out-of-network copayment for specialist office.  
 
  You have been asked to pay $99.61for intravitreal injection and injection of drug. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
September 26, 2022 Intravitreal 
injection 
$69.23 50% $34.61 
September 26, 2022 Injection of drug $112.16 $65 $65 
Total:    $99.61 
 
This item/service falls within the Medicare Part B prescription drugs and Vision care 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 intravitreal injection and injection of drug provided on 
September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid. 
 
You asked the Plan to pre-approve Synthroid. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug 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 Synthroid.  
 
Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a localized delivery of antimicrobial agents (D4381) for teeth 
numbers 28, 29, 14, 15, 30 provided on June 13, 2022. 
 
You asked the Plan to pay for a localized delivery of antimicrobial agents (D4381) for teeth numbers 28, 29, 
14, 15, 30. You say that all the activities were done on the same date due to the mobility difficulties that you 
have due to your age, and the problems it would cause you to have to come on two different days. The Plan 
denied your request. The Plan says there is no coverage for localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue, per tooth (D4381 x5). 
 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. Therefore, we decided that the Plan does not have to pay for a 
localized delivery of antimicrobial agents (D4381) for teeth numbers 28, 29, 14, 15, 30 provided on June 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve the requested services. You say that the device helps your shoulder since the 
repair. The Plan denied your request. The Plan says you have not had a total knee replacement. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
We looked at the file and the rules. You have not had total knee replacement surgery. Therefore, we decided 
that the Plan does not have to pre-approve a continuous passive motion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block (64454). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is considered 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve block is 
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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the genicular nerve block (64454).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home healthcare services provided to the enrollee from December 30, 2021, to January 28, 2022.
You asked the Plan to pay for the home healthcare services. You say that these services were medically necessary. 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. Medicare rules say that the RAP contains the same date in both the "from" and "through" date fields. We looked at the file and Medicare rules. The RAP form submitted does not contain the same date in both the "from" and "through" date fields. Based on this information, we decided that Medicare rules for coverage of the home healthcare services have not been met. Therefore, we decided that the Plan does not have to pay for the home healthcare services provided to the enrollee from December 30, 2021, to January 28, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the chiropractic manipulation provided on June 15, 2022, billed 
with code 99842. We decided that the Plan does not have to pay for the services provided on these dates 
described by code 97124.  
 
You asked the Plan to pay for the services provided between May 25, 2022, and July 6, 2022.. You say that the 
claim should be paid as billed. The Plan says that some of the codes were approved. However, 97124 cannot be 
paid on the same date as 97140. Also, the MUE was exceeded for code 99842. 
 
We decided that the Plan has to pay for the chiropractic manipulation provided on June 15, 2022, billed 
with code 99842.  
 
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. 
 
In this case, the Plans rationale was not supported. The Plan states this was denied for exceeding the MUE, but 
the MUE was 1 and only one unit was billed for this date of service. Therefore, we decided that the Plan has to 
pay for the chiropractic manipulation provided on June 15, 2022, billed with code 99842.  
 
We also decided that the Plan does not have to pay for the services provided on these dates described by 
code 97124. 
 
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 97124 
is a column II code to column I code 97140 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 the services provided on these dates described by code 97124. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the requested services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the treatment is not the standard of care for skin cancer. 
 
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 usually IGRT is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this enrollee for which the target 
lesion can be seen on the skin to assist in daily set up. Daily simulations or IGRT would not be furnished in 
accordance with accepted standards of medical practice. 
 
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 image guided radiation therapy (IGRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xF liquid biopsy testing provided to the enrollee on April 5, 2022.
You asked the Plan to pay for the genetic testing. You say that this is medically necessary and should be paid. The Plan denied your request. The Plan says the specimen was obtained during a hospital outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid biopsy testing provided to the enrollee on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (86618, 86617, 36415) provided on July 26, 
2021. 
 
You asked the Plan to pay for the lab services. You say that you were waiting on the enrollee's diagnosis. The 
Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until October 11, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services (86618, 86617, 36415) provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 33967, 76937, and 93456 provided to the
enrollee on June 30, 2021.
You asked the Plan to pay for procedure codes 33967, 76937, and 93456. You say that you would like the Plan
to reconsider their denial of payment. The Plan denied your request. The Plan says that the claim needs to be
submitted to the primary carrier.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for procedure codes 33967, 76937, and 93456 until the primary insurer has denied the claim for these services.
Therefore, we decided that the Plan does not have to pay for procedure codes 33967, 76937, and 93456
provided to the enrollee on June 30, 2021.