Persius/hicric huggingface dataset:
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 admission is medically necessary. The Plan 
denied your request. The Plan says your condition does not meet all of the requirements for inpatient 
rehabilitation admission.  
 
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 in this case, the complexity of your nursing, medical and rehabilitation needs do 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement; however, the documentation doesnt support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain his functional status.  You 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 pre-approve proton beam radiation therapy (77525). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested service is a 
necessity for your care. The Plan denied your request. The Plan says the requested service is 
experimental/investigational for your condition. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that any potential benefit or detriment of proton therapy over standard intensity-
modulated radiation therapy (IMRT) is an investigational question. Whether proton therapy affords a benefit 
over standard approaches for prostate cancer is an area of investigation and remains controversial. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77525).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on June 01, 2023. 
 
You asked the Plan to pay for an injection. You say that you are requesting reconsideration for the denied 
claim. 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 injection provided on 
June 01, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient observation services, and self-administered 
drugs provided July 2, 2023, to July 4, 2023. 
 
You asked the Plan to pay for the hospital services. You say that you were admitted for severe electrolyte 
imbalance and your sodium was at a dangerous level. 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 $200 
copayment for Outpatient hospital observation.  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. 
 
You have been asked to pay $548 ($200 copayment and $348 self-administered drugs) for the hospital services. 
This item/service falls within the Medicare Part B prescription drugs and Outpatient hospital observation 
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 pay for the outpatient observation services, and self-
administered drugs provided July 2, 2023, to July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional fractions of intensity-modulated
radiation therapy (IMRT) for the enrollee.

You asked the Plan to pre-approve five (5) additional fractions of IMRT. You say that you disagree with the
denial. The Plan denied your request. The Plan says that the services are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for five (5) additional
fractions of IMRT. Our Medical Director states that 10 fractions of IMRT are medically reasonable and
necessary in this case, as multiple targets with a complex volume are being treated. 10 fractions of IMRT
would be furnished in accordance with accepted standards of medical practice. 15 fractions of IMRT would not
be considered medically reasonable and necessary. Our Medical Director found that the enrollee's condition
does not meet criteria for coverage of five (5) additional fractions of IMRT.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of five (5) additional fractions of IMRT have not been met. Therefore, we decided
that the Plan does not have to pre-approve five (5) additional fractions of intensity-modulated radiation therapy
(IMRT) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99233) 
rendered on February 13, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation more supports CPT 99231. 
 
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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee suffered an arrest 
after meningioma resection. The documentation does not support a high-level of decision-making or more than 
50 minutes of time spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99233) rendered on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional tooth added to an existing denture (D5650) 
provided on July 24, 2023. 
 
You asked the Plan to pay for D5650. You say that you do not agree with these charges. The Plan denied your 
request. The Plan says the denied dental service is not a covered benefit. 
 
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 an 
additional tooth added to an existing denture (D5650) provided on July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx Sensoready. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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. Therefore, we decided that the Plan does not have to pre-approve Cosentyx Sensoready.   
Benefits for these services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on April 19, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx UTI-ABR Molecular Test Panel provided on 
June 20, 2023, and billed with codes 87481, 87798, and 87801. 
 
You asked the Plan to pay for the Altru Dx UTI-ABR Molecular Test Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Altru Dx UTI-ABR Molecular Test Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx UTI-ABR 
Molecular Test Panel provided on June 20, 2023, and billed with codes 87481, 87798, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oticon Real 2 hearing aids (V5130), purchased on May 
1, 2023. 
 
You asked the Plan to pay for the Oticon Real 2 hearing aids . You say that the items should be covered. The 
Plan denied your request. The Plan says the specific hearing aids you purchased were not listed as part of the 
cost share structure, therefore are not covered.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan says you pay 
a copayment for each hearing aid, and the copayment amount depends on the type of hearing aid purchased. 
Hearing aid types other than the ones listed are not covered. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the Oticon Real 2 hearing aids have not been met. The specific hearing aids you purchased were 
not listed as part of the cost share structure, therefore are not covered Therefore, we decided that the Plan does 
not have to pay for the Oticon Real 2 hearing aids (V5130), purchased on May 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798) provided on April 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, the provided records do not 
describe what service is represented by the not otherwise specified code. The plan requested additional 
documentation and it was not provided. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87798) provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for urgent care services provided on April 10, 2023. 
 
You asked the Plan to reimburse you for the urgent care services. You say that the facility refused to give you 
an itemized bill. The Plan denied your request. The Plan says proof of payment is not line itemized showing 
what services were rendered and therefore not sufficient. 
 
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 urgent care services have been met. Specifically, proof of payment is required and was not provided to the Plan. Therefore, we decided that the 
Plan does not have to reimburse you for urgent care services provided on April 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services provided on October 18, 
2022. 
 
You asked the Plan to pay for the inpatient mental health services. You say that you would like the Plan to 
reconsider its denial. The Plan denied your request. The Plan says you have not provided any medical records 
to support the necessity of these services. 
 
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 inpatient mental health services 
have been met. Specifically, you have not provided any medical records to support the billing of these services, 
despite requests from the Plan for those records. Therefore, we decided that the Plan does not have to pay for 
inpatient mental health services provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 27, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the lung cancer screening with low dose computer
tomography (71271) provided to the enrollee on December 22, 2022.

You asked the Plan to pay for the lung cancer screening with low dose computer tomography. You say that
these services were medically necessary. The Plan denied your request. The Plan says that the criteria for
coverage have not been met. Maximus overturned the Plan's denial. The Plan requested a reopening and stated
that Maximus did not apply the correct criteria. The Plan is correct in this case. According to Medicare rules
the enrollee must be between the ages of 50 and 77 at the time of the screening. The file confirms the enrollee
was outside this age range when these services were received. Based on this information, we decided that
Medicare rules for coverage of the lung cancer screening with low dose computer tomography have not been
met. Therefore, we decided that the Plan does not have to pay for the lung cancer screening with low dose
computer tomography (71271) provided to the enrollee on December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing (87150, 87481, 87798, 87801) 
provided July 20, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says The PCR testing is 
considered 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 looked at the file and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Urine PCR panel testing (87150, 87481, 87798, 87801) provided July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 74240, 74230, 72040, 70100, 
and 70310 billed on March 2, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they were medically necessary. The Plan denied your request. The Plan says the radiology 
services are denied because they were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS. 
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 74230 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, and 70310 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting. There is no evidence the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services coded as 74240, 74230, 72040, 70100, and 70310 
billed on March 2, 2023.