Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy visit provided on 
March 17, 2023, to March 30, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy visit. You say that you want to appeal the 
amount being charged. 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. This item/service falls within the 
outpatient rehabilitation services 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. The total amount you owe is $320 ($40 copayment x 8 visits = $320). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy visit 
provided on March 17, 2023, to March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 7, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 2, 2023, billed with 
codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, 81401, and 81329. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 2, 2023, billed with codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, 81401, and 81329.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service November 6, 
2022. 
 You asked the Plan to pay for procedure code 99223. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99223 is bundled into payment for code 61645. 
 
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 99223 
is a column II code to column I code 61645. 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 99223 billed for date of service November 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a water circulating heat pad with pump (E0217) provided 
December 5, 2022, to December 22, 2022. 
 
You asked the Plan to pay for  a water circulating heat pad with pump. You say that this enrollee's medical 
necessity actually meets the guidelines that qualify for coverage. Additionally, there is evidence based medical literature that substantiates the efficacy of the treatment rendered. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for  a water circulating heat pad with pump (E0217) provided December 5, 2022, to 
December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on April 25, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that your doctor told you that the shingles shot was 
covered. The Plan denied your request. The Plan says the immunizations are covered under part D and can be 
submitted for reimbursement. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on April 
25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that it is medically necessary. The Plan 
denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic services Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
cervical and low back pain from subluxation as well as other non-spinal musculoskeletal complaints. The records of these visits do not support progressive improvement of symptoms but rather maintenance therapy. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is not 
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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 5, 2022, to May 27, 
2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA timely. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 5, 2022. The NOA was not received by the Plan until July 8, 2022. As 
more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for home health services provided from May 5, 
2022, to May 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 4, 2022, to July 3, 
2022. 
 You asked the Plan to pay for the home health services. You say that you believe you submitted the NOA in a 
timely manner. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 4, 2022. The NOA was not received by the Plan until July 20, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
June 4, 2022, to July 3, 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services at a 
lower 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 pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on November 30, 2022. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that it is 
medically necessary. The Plan denied your request. The Plan says this is an administrative determination or 
non-coverage and is not based on clinical criteria for medical necessity. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on January 27, 2023, to January 28, 
2023. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you cannot afford the full cost of the 
inpatient stay.  The Plan denied your request. The Plan says that they were not notified within 48 hours of the 
emergency for Plan approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, there were no medical records provided for review, nor was there 
evidence of the Plan having made reasonable attempts to obtain medical records. Without this necessary 
information, the Plan has not substantiated that the enrollee was stabilized, and emergency care had ended. 
Therefore, we decided that the Plan has to pay for inpatient hospital services provided on January 27, 2023, to 
January 28, 2023.  
 
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 continuation of Gammagard (intravenous immune 
globulin - IVIG). 
 
You asked the Plan to pre-approve continuation of IVIG. You say that the enrollee currently manages their 
condition with azathioprine daily and IVIG every two weeks. You say that the enrollee has been doing well on 
this regimen. You say that you would like to continue these infusions at the same rate of every two weeks. You 
also say that the enrollee has a significant return of symptoms if IVIG is delayed. The Plan denied your request. 
The Plan says a one-time dose is not indicated for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continuation of IVIG. Our reviewer 
says that the request for the continuation of IVIG is not medically necessary. Our physician reviewer found an extra dose of Gammagard is not Food and Drug Administration-approved for weakness after a rituximab 
infusion in a patient with myasthenia gravis. Provided records do not document severe myasthenia with a need 
to treat acute severe decompensation when other treatments have been unsuccessful or are contraindicated. 
Therefore, the reviewer found that the request for the continuation of IVIG 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 continuation of IVIG have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continuation of Gammagard (intravenous immune globulin - IVIG).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 3, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit and supplies provided to the enrollee on August 26, 2022.
You asked the Plan to pay for the electrical stimulator and supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says that the claim did not comply with all Medicare claim payment, billing and coverage policies.
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 the electrical stimulator and supplies have been met. Current medical records have not been provided to confirm the TENS unit was still necessary for the enrollee's care. Therefore, we decided that the Plan does not have to pay for the TENS unit and supplies provided to the enrollee on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87591, 87640, 87653, 
87661 and 87798 billed for January 26, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87481, 87491, 87563, 87591, 87640, 87653, 87661 and 87798 are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87591 is infectious agent detection by nucleic acid (DNA or RNA); 
Neisseria gonorrhoeae, amplified probe technique. The definition of code 87640 is infectious agent detection 
by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique. The definition of code 
87653 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe 
technique. The definition of code 87661 is infectious agent detection by nucleic acid (DNA or RNA); 
Trichomonas vaginalis, amplified probe technique. The definition of code 87798 is infectious agent detection 
by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87481, 87491, 87563, 87591, 87640, 87653, 87661 and 87798 is not supported in the 
medical record. Specifically, the records show that there is no order that specifically lists what tests are to be 
performed. 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 pay for procedure codes 87481, 87491, 87563, 
87591, 87640, 87653, 87661 and 87798 billed for January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that it is imperative that the surrounding critical structures 
be spared as much as possible while providing adequate radiation to the tumor area. The Plan denied your 
request. The Plan says this is unproven and 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while SBRT for oligoprogression is an emerging approach it is not the standard of care at this 
time and would not meet guidelines. Certainly, palliative 3-dimensional radiation could be offered as a standard 
of care approach which conceivably have lower risks of side effects with no known detriment in outcomes.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor and Reader for the enrollee.
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor and Reader. You say that the patient has dementia and uncooperative with a finger prick glucose testing. The Plan denied your request. The Plan says that the medical records submitted do not establish that the Freestyle Libre 2 continuous glucose monitoring sensor and reader is reasonable and necessary. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that the enrollee did not meet criteria for coverage as she was not using insulin. The Plan is correct in this case. The documentation indicates that the enrollee does not use insulin with at least three daily injections.
Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 Sensor and Reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor and Reader for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.