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

 
We decided that the Plan does not have to pay for nail fungus polymerase chain reaction (PCR) panel testing 
provided on February 8, 2022. 
 
You asked the Plan to pay for the nail fungus PCR testing. You say that the nail fungal PCR panel is medically 
necessary. The Plan denied your request. The Plan says nail fungal PCR panel testing is not medically 
necessary and reasonable. PCR testing as a first line approach for evaluation of nail disorders is not widely 
accepted as the standard of care. There is also a lack of data to suggest that these panels alter decision making. 
 
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 nail fungus PCR testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it is well established in the medical documentation that this patient is suffering with 
thick (2mm) painful toenails that demonstrate subungual detritus. A toenail specimen from the right hallux was 
taken and sent for PCR testing to evaluate for pathogens. The longstanding standard of care for the evaluation 
of fungus in toenails is the performance of both potassium hydroxide (KOH) and fungal culture on a toenail 
specimen. These laboratory tests are inexpensive, sensitive, and specific. It is unclear as to why this patients 
toenail required PCR testing as compared to KOH and fungal culture. 
 
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 nail fungus PCR testing have not been met. Therefore, we decided that the 
Plan does not have to pay for nail fungus polymerase chain reaction (PCR) panel testing provided on February 
8, 2022.
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 this level of care can better handle the 
enrollee's medically complex needs. The Plan denied your request. The Plan says the enrollee is receiving the 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test panel (0312U) provided on July 26, 
2022. 
 You asked the Plan to pay for the AVISE CTD test panel. You say that this testing was deemed medically 
necessary by the enrollee's physician. The Plan denied your request. The Plan says screening genetic testing is 
not covered. 
 
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 test at issue in this appeal, the AVISE CTD test panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the AVISE CTD test panel (0312U) provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation (D7953) provided on November 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
on November 8, 2022. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you were not 
informed of the cost share. 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 $350 
copayment per day, for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $350 copayment for the myocardial perfusion imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would like to continue to your provider.. 
The Plan denied your request. The Plan says this is available in-network. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a friction stance phase control (L5822) and stance 
flexion feature (L5845). 
 You asked the Plan to pre-approve a friction stance phase control and stance flexion feature. The Plan denied 
your request. The Plan says this request for K3 knee does not meet Medicare criteria as reasonable and 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
(L5822) is covered for beneficiaries whose functional level is 3 or above. 
 
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 friction stance phase control and 
stance flexion feature. Our reviewer says that the Plan is correct to deny the requested knee, given the medical 
record submitted. Our physician reviewer found it is clear that the practitioners in this case are attempting to 
provide a relatively low-tech prosthetic design for this enrollee, as evidenced by their not having requested a 
microprocessor knee (which would be the clinical standard if the enrollee had K3 level potential). However, 
Medicare policy still reserves all pneumatic and hydraulic knee technology (microprocessor and non-
microprocessor types) for K3 level ambulators. Our reviewer also found that the Plan is correct to deny K3 
level componentry given that the record is consistent in grading the enrollee as K2. 
 
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 friction stance phase control and stance flexion feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a friction stance phase control (L5822) and 
stance flexion feature (L5845).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test billed for date of service November 21, 
2022. 
 You asked the Plan to pay for the billed services. You say that medical necessity of the test is well established. 
The Plan denied your request. The Plan says the test is not covered. 
 
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. Local Coverage Determination for Biomarkers for Oncology, 
L35396, reaffirms non-coverage for the CxBladder test. The records also show that the test is not FDA 
approved. 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 CxBladder test billed for date of 
service November 21, 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 due to significant comorbidities, medical complexity 
and the ability to tolerate and benefit from an intensive rehabilitation program, the enrollee would benefit from 
close daily medical supervision at an IRF. 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the breast prosthesis (L8030) and mastectomy bra (L8000) provided on 
May 20, 2022. 
 
You asked the Plan to pay for the breast prosthesis and mastectomy bra. You say that the enrollee did have a 
visit with the provider within 6 months of the items that were provided. The Plan denied your request. The Plan 
says that this claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. Medicare rules also say that 
a mastectomy bra (L8000) is covered for a patient who has a covered mastectomy form (L8020) or silicone (or 
equal) breast prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis. 
 
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 breast prosthesis and mastectomy bra. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical documentation confirms the enrollee has had a right-sided 
mastectomy. There is additional documentation that indicates the enrollee had an ill-fitting breast prosthesis 
that was causing additional pain and required replacement and subsequently new mastectomy bras. Our 
reviewer also found that the requested mastectomy bras were 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 breast prosthesis and mastectomy bra have been met. Therefore, we decided 
that the Plan has to pay for the breast prosthesis (L8030) and mastectomy bra (L8000) provided on May 20, 
2022.  
 
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: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for chest pain and ventricular fibrillation. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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: 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 you had a stroke and have right sided weakness. You 
say your speech, mobility and health have declined without therapy. The Plan denied your request. The Plan 
says the IRF services you are requesting 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 the Plan does not have to pay for medical services provided to the enrollee on October 15, 2021.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request.
The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. On a review for
date error, it was discovered the incorrect criteria was applied by Maximus.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service. The record shows that a claim for
payment not filed until December 14, 2022. This means that more than one calendar year from the date of
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for
medical services provided to the enrollee on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve an artery embolization. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the requested procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an artery embolization. Our reviewer 
says that the requested item/service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. While the studies are noted 
to be promising, further studies/research is needed to corroborate that geniculate artery embolization is as good as or better than standard treatments for knee osteoarthritis. Moreover, there were no diagnostic imaging 
studies provided. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception.  
 
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 artery embolization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular artery embolization (36246, 36247).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need additional trips to get back and forth 
to your doctor's appointments. The Plan denied your request. The Plan says any additional trips beyond the 
allowed 24 one-way trips are not covered. 
 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 covers a maximum of 24 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 additional trips cannot be approved. The record shows that you have ten one-way trips still available. 
Additionally, the Evidence of Coverage clearly states that you are responsible for any costs over the trip limit. 
Therefore, we decided that the Plan does not have to pre-approve 24 additional transportation trips.