Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast implant removal for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this would benefit the enrollee for continued
recovery after the bypass surgery. The Plan denied your request. The Plan says that there is no indication that
symmetry needs to be established after breast cancer surgery.

The Plan must follow Medicare rules. The rules say that complications related to breast implants may
potentially increase over time which could result in the need for removal.

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 procedure. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee had previously had breast augmentation and recently had cardiac
surgery necessitating removal of an implant. The record indicates that the enrollee now has asymmetry which is
a deformity. The record indicates that the requested service is reconstructive in nature. The elements of the
coverage criteria are satisfied.

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 procedure have been met. Therefore, we decided that the Plan has to pre-approve
breast implant removal for the enrollee.

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 the CPAP device (CPT code E0601) and humidifier (CPT code E0562).

You asked the Plan to pre-approve the CPAP device. You say that the machine is under recall. You state the company called you and said to not use it otherwise you will get cancer. The Plan denied your request. The Plan says they do not have evidence that you need a new CPAP. The Plan states they do not have evidence that you are unable to use your current device. The Plan states the CPAP may only be approved for medical necessity and they do not have evidence that a new CPAP is medically necessary.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met. Please call Phillips Respironics company to register the serial number of the machine and consult with your doctor if you need continuation of CPAP; not all CPAP machines are on recall. Therefore, we decided that the Plan does not have to pre-approve the CPAP device (CPT code E0601) and humidifier (CPT code E0562).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from March 31, 2021, to April 5, 2021.

You asked the Plan to waive the copayment for inpatient hospital services. You say that these charges were pharmacy charges incurred during the hospital stay. You also say that you do not know what prescriptions the Plan covers and none of your prescriptions are expensive. You also say they should have requested predetermination of these drugs, so you do not feel responsible for these charges. The Plan denied your request. The Plan says you were 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 $295 copayment for inpatient hospital care. 

You have been asked to pay a $295 copayment per day, for days 1 to 5 for inpatient hospital care for a total of $1,475 ($295 copayment x 5 days = $1,475). The record shows that these charges are for the copayments. 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 inpatient hospital services provided from March 31, 2021, to April 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that certain services cannot be rendered where the 
enrollee is currently located. The Plan denied your request. The Plan says criteria for admission to the IRF 
setting have not been met. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 13, 2021. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the physician only provided 
medically necessary services to the enrollee in good faith, and the rendered services meet professionally 
recognized standards of healthcare. The Plan denied your request. The Plan says when the enrollee enrolls in a 
Medicare-certified hospice program, the enrollee's hospice services and Part A and B services related to the 
terminal prognosis are paid for by Original Medicare, not the Plan.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 27, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made for the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT codes 99100 and 99140 are bundled codes. When these services are covered, payment for 
them is subsumed by the payment for the services to which they are incident. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services provided on April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device for the enrollee.
You asked the Plan to pre-approve a Cala Trio nerve stimulator device. You say that this device is medically
necessary. The Plan denied your request. The Plan says this device is not covered by Medicare. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Cala Trio nerve
stimulator device. The Maximus Physician Reviewer determined that the requested nerve stimulator device was
medically reasonable and necessary in this case. The Plan argues that the Cala Trio wearable device is not
supported by evidence based on medical guidelines or peer-reviewed literature and is considered experimental
and investigational. The Plan notes that a review of the medical record did not demonstrate that the enrollee
had exhausted all treatments that would be considered standard of care. The medical records show the enrollee
has essential tremor. The enrollee presented to the Family Medicine office on June 24, 2021 to discuss approval
for treatment of his bilateral upper extremity benign essential tremor. It is documented that the enrollee was
already taking a beta-blocker medication and a calcium channel blocker due to his recurrent atrial fibrillation.
The enrollee had engaged in massage therapy and physical therapy. "None of the previous treatment modalities
has been successful in lessening the left upper extremity tremor." The enrollee had been seen by neurology, and
no new or other testing or treatments were recommended or planned. The enrollee had been told that there was
no cure, and that he would have to live with the tremor. Examination showed moderate to severe resting of both
upper extremities, left greater than right, which was worse with intention. The Family Physician documents,
"The patient would like to try a peripheral nerve stimulator called Cala Trio on the left upper extremity.
Our Medical Director has determined the Plan is correct in this case. The documentation does not support that
the requested Cala Trio nerve stimulator device is medically reasonable and necessary for the enrollee in this
case. Rather, the device would be considered experimental and investigational at this 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 a Cala Trio nerve stimulator device have not been met. Therefore, we decided
that the Plan does not have to pre-approve a Cala Trio nerve stimulator device for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) provided on June 8, 2021. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says that the records do not document at least 22 drug classes were tested. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that more than 
22 drug classes were tested on this date of service. The records show that the classes tested include Alcohol 
biomarkers; Amphetamines; Antidepressants, serotonergic class; Antidepressants, tricyclic and other cyclicals; 
Antidepressants, not otherwise specified; Antipsychotics, not otherwise specified; Barbituates; Benzodizepines; 
Buprenorphine; Cannabinoids, natural; Cannabinoids, synthetic; Cocaine; Fentanyls; Gabapentin, non-blood; 
Heroin metabolite; Ketamine and Norketamine; Methadone; Methylenedioxyamphetamines; Methylphenidate; 
Opiates; Oxycodone; Phencyclidine; Pregabalin; Propoxyphene; Sedative Hypnotics (non-benzodiazepines); 
Skeletal muscle relaxants; Stimulants, synthetic; Tapentadol; and Tramadol. Based on this information, we 
decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan 
has to pay for drug testing (G0483) provided on June 8, 2021.  
 
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 Mobile Cardiac Outpatient Telemetry Monitor 
(CMOT). 
 
You asked the Plan to pre-approve the CMOT. You say that the CMOT is necessary. The Plan denied your 
request. The Plan says the records did not indicate medical necessity. 
 
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 CMOT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there was no report of having remote Holter or Event monitoring which are cost-effective ways 
to monitor for arrhythmias. Outpatient telemetry is not supported as there was no provided evidence of failure 
or inappropriateness of these other monitoring options. Therefore, the CMOT is considered 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 CMOT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Mobile Cardiac Outpatient Telemetry Monitor (CMOT).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the comprehensive cardiomyopathy panel provided on March 8, 2021, 
billed with codes 81439, 81407, 81403, 81404, 81405, and 81406. 
 
You asked the Plan to pay for the comprehensive cardiomyopathy panel. You say that this was medically 
necessary testing that should be covered. The Plan denied your request. The Plan says that the member had 
genetic cardiovascular risk assessment testing on March 8, 2021. The denial remains upheld as noncovered as 
Medicare denies coverage for all cardiovascular genetic risk assessment panels. Medicare only covers a lipid 
panel for cardiovascular disease screening. 
 
Maximus reviewed the denial rationale provided by the Plan and finds it is not applicable. No rule was 
provided that states that all cardiovascular genetic risk assessments are noncovered. While it is true that 
Medicare only covers a lipid panel for cardiovascular disease screening, the reported presence of arrhythmia 
and shortness of breath would indicate that this cannot be considered a screening test as there is known 
cardiovascular disease. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the comprehensive cardiomyopathy panel by a contract provider. The file does 
not show that the plan provided notice that the comprehensive cardiomyopathy panel would not be covered, nor 
that there is a Medicare coverage rule which would preclude payment. Under Medicare rules, this means the 
comprehensive cardiomyopathy panel is considered approved by the plan. Therefore, we decided that the Plan has to pay for the comprehensive cardiomyopathy panel provided on March 8, 2021, billed with codes 81439, 
81407, 81403, 81404, 81405, and 81406.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Xarelto tablet. 
 
You asked the Plan to pre-approve the Xarelto tablet. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says this is a self-administered drug. 
 
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 the Xarelto tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to fully pay for the dental services provided on July 29, 2021. 
 
You asked the Plan to fully pay for the dental services. You say that you accidentally broke the tooth while 
eating and that was traumatic. You say that this was not cosmetic and should be treated as medical. The Plan 
denied your request. The Plan says the full $3,000 dental allowance for the year was paid. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
$3,000 for preventive and comprehensive dental services every year. The Plan paid $3,000 toward the dental 
services received on July 29, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not 
have to fully pay for the dental services provided on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided on April 5, 2021. 
 You asked the Plan to pay for the testing services. You say that you have no knowledge of the enrollee's 
coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says 
screening testing is not a Medicare benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing panel was requested solely for screening purposes. Medicare does not cover this testing solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing panel 
provided on April 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on June 19, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on June 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the eyeglasses purchased on April 5, 
2021. 
 
You asked the Plan to provide reimbursement for the eyeglasses. You say that you were told this was an in-
network provider and are frustrated that you are not able to get reimbursement for this cost. The Plan denied 
your request. The Plan says you have exhausted your vision benefit allowance. Additional reimbursement 
cannot be provided. 
 
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 covers up to $150 per calendar year for one pair of standard eyeglasses or contact lenses 
purchased from a provider in the Plan's specified vendor network. If you use an in-network provider, the claim 
will be processed at the time of service. You are responsible for any remaining balance. 
 
We looked at the file and the Plan's rules. Documentation shows that this claim was processed at the time of 
purchase. The total cost of the eyeglasses was $224. The Plan covers up to $150 for routine eyewear per 
calendar year when purchased in-network. You are responsible for the remaining cost. ($224 - $150 = $74). 
The Plan has covered the $150 allowance as stipulated in the contract. This means you have been asked to pay 
the correct amount based on your contract with the Plan and are not entitled to additional reimbursement. 
Therefore, we decided that the Plan does not have to provide reimbursement for the eyeglasses purchased on 
April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 11, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 11, 2020.