Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Omnigraf panel (81479) provided on February 7, 2023. 
 
You asked the Plan to pay for the Omnigraf panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of OmniGraf testing in the setting of 
kidney transplantation have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the Omnigraf panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no accompanying documentation that speaks to medical justification of this 
test. There is no supportive clinical indication. The documentation was requested by the insurer, but not 
provided. Thus, based on the information provided, this test was not medically reasonable and 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 Omnigraf panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the Omnigraf panel (81479) provided on February 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
September 14, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the provider should 
be responsible for the bill. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room services. This item/service falls within 
the emergency 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 emergency room 
services provided on September 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a black fender color option. 
 
You asked the Plan to pre-approve a black fender color option. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The requested 
fender color option is considered an upgrade that is not covered. Therefore, we decided that the Plan does not 
have to pre-approve a black fender color option.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76882) provided on July 10, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that a licensed physical therapist is allowed to perform 
code 76881. The Plan denied your request. The Plan says there is no order from the enrollee's primary care 
physician (PCP) or attending physician for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that an "order" is a communication from the treating 
physician/practitioner requesting that a diagnostic test be performed for a beneficiary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have not been met. The records provided did not include an order for the diagnostic 
test in dispute from a treating physician/practitioner. The only records that were provided were an Ultrasound 
Report. This document did not list a referring physician and was signed by a Doctor of Physical Therapy 
(DPT). A DPT is not considered a physician according to Medicares rules. The case file shows that the Plan 
made reasonable attempts to obtain the necessary medical records demonstrating that the ultrasound was 
ordered by a treating physician/practitioner. Therefore, we decided that the Plan does not have to pay for the 
ultrasound (76882) provided on July 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on May 3, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the provided documentation supports an appropriate history and examination and a moderate complexity 
presentation, as the enrollee was stable on admission. The documentation did not sufficiently support the code 
99285 due to insufficient support of high level of medical decision-making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on May 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexamethasone. 
 
You asked the Plan to pre-approve the medication. You say that this is necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
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. Additionally, the record indicates that the requested drug is not being used to prevent nausea 
due to chemotherapy. Therefore, we decided that the Plan does not have to pre-approve dexamethasone.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service June 19, 
2023. 
 You asked the Plan to pay for procedure code 99024. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says procedure code 99024 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service June 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on May 22, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the provided documentation supports an appropriate history and examination, but does not support a high level 
of medical decision-making to justify the code, 99285, for this encounter.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colostomy supplies provided on March 18, 2023. 
 
You asked the Plan to pay for colostomy supplies. You say that this should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for colostomy supplies 
provided on March 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva.  
 You asked the Plan to pre-approve Xgeva. You say that the drug is medically necessary for treatment. The Plan 
denied your request. The Plan says Xgeva is not being prescribed for a medically accepted indication. 
 
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 Xgeva. Our reviewer says that Xgeva is 
denied and Prolia is approved under the enrollee's Part B coverage. Our physician reviewer found there is no 
documentation provided indicating that the plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain imaging/positron emission tomography (PET); 
metabolic evaluation 
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says based on the additional information available, the request does not meet the 
Medicare or health plan coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that there was no discussion in the records 
of possible frontotemporal temporal dysplasia. This is a Medicare requirement for approval of this scan. This is 
only covered when there is a differential diagnosis of Alzheimer's disease and fronto temporal dysplasia.  
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brain imaging/positron emission tomography (PET); metabolic evaluation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5211) and a lower partial
denture (D5212).

You asked the Plan to pre-approve an upper partial denture and a lower partial denture. You say that you are
requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that you have
exhausted the allowable benefit for the dental items requested in this case. Maximus overturned the Plan's
denial because of a lack of information. The Plan requested a reopening and stated that this is not covered by
the enrollee's Medicare benefit. The Plan is correct in this case. The Plan provided the 2023 Dental Benefit
Details document which lists all the covered services. Upper and lower partial dentures are not listed in the
document and therefore not a covered service. Therefore, we decided that the Plan does not have to preapprove
an upper partial denture (D5211) and a lower partial denture (D5212).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the travel allowance billed with code P9603 for date of 
service August 4, 2023. 
 
You asked the Plan to pay for the travel allowance. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that travel allowance is only covered when the 
specimen collection fee is also payable. 
 
We looked at the file and Medicare rules. Review of the file shows that the only code on this claim was code 
P9603. A specimen collection fee was not billed with this claim. This claim is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of the travel allowance have not been met. 
Therefore, we decided that the Plan does not have to pay for the travel allowance billed with code P9603 for 
date of service August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from May 12, 2023, to June 1, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that their original decision to deny payment was correct. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided from May 12, 2023, 
to June 1, 2023, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on March 14, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
that the history and examination documentation were appropriate, but the documentation did not sufficiently 
support a high level of medical decision-making required to justify the code, 99285, for this encounter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on August 17, 2023. 
 
You asked the Plan to pay for an x-ray. You say that this was medically necessary and should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an x-ray provided on 
August 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  ambulance service, conventional air services (A0430), and 
air mileage (A0436) provided on April 9, 2023.  
You asked the Plan to pay for  the air ambulance services. You say that the fixed wing air transport in this case 
was medically necessary to reduce out of hospital time and the medical records provided support the medical 
necessity. The Plan denied your request. The Plan says after reassessing the entire clinical situation, 
information provided at the time of the appeal does not support criteria for air ambulance transport. There are 
multiple closer facilities with appropriate services to treat the enrollee. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for  the air ambulance services. Our reviewer 
says that the services were not medically necessary. Our physician reviewer found while the transfer may have 
been medically necessary due to the lack of intensive care unit staffing, it does not appear that the enrollee was 
transported to the closest appropriate facility. As such, the air medical transport is not coverable. 
 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for  ambulance service, conventional air services (A0430), and air mileage (A0436) 
provided on April 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve administration of Botox with an 
esophagogastroduodenoscopy (EGD). 
 
You asked the Plan to pre-approve Botox with EGD. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that Botox may be covered for labelled or certain off-
label 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 Botox with EGD. Our reviewer says 
that the enrollee does not meet criteria for this procedure. Our physician reviewer found the enrollee has 
gastroesophageal reflux disease (GERD), nausea, and vomiting in the setting of type 2 diabetes. A gastric 
emptying scan on 11/30/2023 was consistent with mild gastroparesis for solid food. There was no evidence of 
GERD. The enrollee does not have an off-label indication for Botox which may be considered medically 
reasonable and 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 Botox with EGD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve administration of Botox with an esophagogastroduodenoscopy (EGD).