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

 
We decided that the Plan does not have to pay for platelet-rich plasma therapy provided on June 2, 2022. 
 
You asked the Plan to pay for platelet-rich plasma therapy. You say that the surgery was done in-network. The 
Plan denied your request. The Plan says platelet-rich plasma therapy is not a covered benefit. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of platelet-rich plasma therapy have been 
met. Specifically, no medical records have been provided to review. Therefore, we decided that the Plan does 
not have to pay for platelet-rich plasma therapy provided on June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is high risk for hospital 
readmission without this equipment. The requested device is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator is not covered. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in a volume assured pressure support (IVAPS or AVAPS) 
mode which could be provided by a bilevel positive airway pressure (BiPAP) device with average volume 
assured pressure support (AVAPS) and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  a Healthy Food Allowance. 

You asked the Plan to provide coverage for  a Healthy Food Allowance. You say that you are on a fixed income and need the Plan to approve the healthy food allowance.  The Plan denied your request. The Plan says you do not have a medical condition that qualifies for this benefit. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided the required information. 

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all coverage information. Your contract with the Plan says that you must have a specific diagnosis to have the Health Food Allowance covered. Based on the medical records provided, you have hypertension. This is not a qualifying diagnosis for this benefit. Therefore, we decided that the Plan does not have to provide coverage for  a Healthy Food Allowance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
February 22, 2023, through March 2, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be 
covered. 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 #220 
copayment per a day for inpatient hospital care.  
 
You have been asked to pay a $220 copayment per a day for the inpatient hospital care. This item/service falls 
within the inpatient hospital 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 copayment for 
the inpatient hospital care provided on February 22, 2023, through March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive  the 20% coinsurance charged for anesthesia services provided on October 26, 2022.

You asked the Plan to waive  this cost share. You say that you do not believe this cost share is correct.  The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial as a billing error. The Plan requested a reopen and stated that Maximus did not apply the correct decision criteria. 

The Plan is correct in this case. 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 20% coinsurance for outpatient surgery services, which would include payment for anesthesia services. 
The criteria applied in the original decision is for claims submitted by the provider, not enrollees cost share. Based on the records provided, 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 20% coinsurance charged for anesthesia services provided on October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sit to stand system. 
 
You asked the Plan to pre-approve a sit to stand system. You say that the enrollee has limited mobility and is 
unable to walk. He was in hospice care through June 2023, and he was provided with a Hoyer sit to stand lift. 
Since he is no longer in hospice, they are requesting to retrieve their equipment. The enrollee needs the sit to 
stand system due to his declining health. The Plan denied your request. The Plan says the requested system is 
not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The requested item is not covered by Medicare or the plan. Based on 
this information, we decided that Medicare rules for coverage of a sit to stand system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a sit to stand system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 9, 
2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87481 is bundled into payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. 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 procedure code 87481 billed for date of service December 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like to appeal to be fully covered because you have paraplegia. The Plan denied your request. The 
Plan says these services cannot be covered as it is not medically necessary to control the three approved power 
options through the joystick (drive interface). 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have paraplegia, but are able to feed 
yourself and perform upper body activities of daily living at a modified Independence level. You have adequate 
strength to manage standard power drives. Our reviewer also found that an expandable controller is not 
medically necessary to meet your needs. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87631, 94761, 99072) provided on October 5, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that providers/suppliers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We also find that procedure code 94761 has a status indicator 
of T on the Physician Fee Schedule. As there are other services payable under the physician fee schedule billed 
on the same date by the same provider, code 94761 is bundled into the physician services for which payment is 
made. Based on this information, we decided that Medicare rules for coverage of codes 99072 and 94761 have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (87631, 94761, 99072) 
provided on October 5, 2022.
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 the enrollee will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says the IRF services requested do not meet the requirements for approval. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each immune globulin injection provided 
on February 07, 2023, to February 28, 2023. 
 
You asked the Plan to reduce the coinsurance for each immune globulin injection. You say that this cost is 
more than your stay in the hospital. 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for each immune globulin injection. This item/service falls 
within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for 
each immune globulin injection provided on February 07, 2023, to February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and footbox (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and footbox. You 
say that there is no reason this should have been denied. The Plan denied your request. The Plan says although 
there are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The Plan also says the footbox (K0108) is miscoded. 
 
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 an electronic connection, harness, 
expandable controller, and footbox. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has left hemiplegia 
without impairment on their dominant right. The enrollee is able to feed themself. Our reviewer found that the 
enrollee has adequate strength to manage standard power drives. An expandable controller is not medically 
necessary to meet the enrollee's needs. Our physician reviewer also found that the footbox has an HCPCS code 
and should not be coded as K0108. 
 
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 electronic connection, harness, expandable controller, and footbox have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), 
harness (E2313), expandable controller (E2377), and footbox (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37224 and 36248 for date of service 
December 31, 2021. 
 
You asked the Plan to pay for procedure codes 37224 and 36248. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT code 37224 and 36248 is not supported in the medical record. Specifically, the operative 
report did not include documentation of an open or percutaneous endovascular revascularization of a unilateral 
femoral or popliteal artery(s), with transluminal angioplasty; therefore, code 37224 is not supported. 
The operative report did not include documentation of a selective catheter placement, into the arterial system; 
for a placement in the additional second order, third order, and beyond, abdominal, pelvic, or lower extremity 
artery branch, within a vascular family (listed in addition to code for initial second or third order vessel as 
appropriate); therefore, code 36248 cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 37224 and 36248 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 37224 and 36248 for date of service December 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's records do not show that you require 
continued treatments that can only be given in a hospital setting. Services needed may be provided safely in a 
lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone density scan to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a bone density scan. You say that you need this scan. The Plan denied your 
request. The Plan says this service is available from multiple in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a bone density scan to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial denture (D5214) for the enrollee.

You asked the Plan to pre-approve the dental services. You say that the requested item or service is a medical necessity for the enrollee. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted.

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, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service March 29, 2022. Therefore, we decided that the Plan does not have to pre-approve a partial denture (D5214) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 22, 2022, billed with 
codes 81201, 81307, 81321, 81351, 81405, and 81406. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says panel testing 
should be billed using one CPT code on the claim. 

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 billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 
22, 2022, billed with codes 81201, 81307, 81321, 81351, 81405, and 81406.