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

We decided that the Plan does not have to waive or reduce the coinsurance charged for the leuprolide acetate
injection provided on November 23, 2022.

You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this coinsurance is
correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
calculations. The Plan noted the Medicare allowed amount for this injection is $499.41 not $491.42 indicated
by Maximus Reviewer. Twenty percent (20%) of $499.41 is $99.88 not $98.28. The Maximus Reviewer did
not use correct Medicare allowed amount for the 2022 service date.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan
clearly says that you must pay 20% coinsurance for Medicare Part B drugs.

You have been asked to pay the correct amount ($99.88) 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 or reduce the coinsurance charged for the leuprolide acetate injection provided
on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
periapical first x-ray (D0220), bitewing x-ray (D0270), 2D oral/facial photographic image (D0350) and core 
buildup (D2950) provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that your providers network status should be 
overlooked this one time and have these services covered under your dental plan. The Plan denied your request. 
The Plan says these services are either not covered benefits or your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0140, D0220 and D0270 was exhausted on dates of service April 13, 2023, and May 
4, 2023. Additionally, D2950 and D0350 are not covered under any circumstance. Therefore, we decided that 
the Plan does not have to pay for the problem focused limited oral evaluation (D0140), periapical first x-ray 
(D0220), bitewing x-ray (D0270), 2D oral/facial photographic image (D0350) and core buildup (D2950) 
provided on June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
testing (87798) provided on February 13, 2023. 
 
You asked the Plan to pay for the respiratory PCR panel testing. You say that this testing was 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 respiratory panels for more than 5 pathogens are 
not covered. 
 
We looked at the file and Medicare rules. In this case the panel at issue tested for more than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of the respiratory PCR 
panel testing.  have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
polymerase chain reaction (PCR) panel testing (87798) provided on February 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 28, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 28, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 28, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of September 28, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 28, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 28, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 28, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (20930). 
 
You asked the Plan to pre-approve an allograft. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is unproven and not medically necessary due to lack of evidence. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Trinity bioactive allograft is experimental in spine surgery. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L1 and L2 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says the coverage criteria have not been met. Onset of pain is noted to be July 
2023. You have documented foraminal stenosis at the L1 and L2 levels. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L1 and L2 kyphoplasty. Our reviewer 
says that you do not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding the worsening of pain. Additionally, there is no documentation of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes of 
pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 and L2 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for lab services provided on
November 5, 2022.

You asked the Plan to waive this copayment. You say that you were told there was no copayment The Plan
denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan
clearly says that you must pay $10 copayment for lab services. Based on the claim submitted by your provider,
this copayment is correct. 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 $10 copayment charged for lab services provided on
November 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service June 
5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim was submitted for the Medicaid 
portion of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on June 22, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulance transportation billed for date of service June 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E1002, E1012, E1028, E2300, 
E2311, E2313, E2361, E2377, E2609, E2617, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that the enrollee is in dire need of new equipment. The Plan denied 
your request. The Plan says the enrollee does not have a medical need for multiple power options included with 
a K0861 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the criteria for 
coverage have not been met. Our physician reviewer found the enrollee does not have high risk for skin 
breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing power 
drive. 
 
 
 
 
 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 group 3 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E0955, E1002, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2609, E2617, and 
K0040).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Collagenase injection rendered on
February 7, 2023.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% of
the cost for in- and out-of-network Medicare-covered Part B prescription drugs.

Review of the file shows that you received a Collagenase injection on February 7, 2023. The previous
determination stated that the Plan had to reduce your coinsurance; however, the file shows that the Plan
correctly applied a 20% coinsurance for these services. You have been asked to pay 20% of the cost for these
services, for a total of $1,165.18. This item/service falls within the in-network and out-of-network Medicarecovered
Part B prescription drugs benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for
the Collagenase injection rendered on February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM)
and supplies.

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 criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage
have been met.

The item at issue is a Freestyle Libre 2 CGM and supplies. The previous determination stated that the services
were medically necessary; however, the file shows that you do not meet the required Medicare criteria for
coverage. We looked at the file and Medicare rules. The documentation indicates that while you have diabetes
and treat with insulin, you do not have a history of recurrent low blood pressure (hypoglycemic) episodes that
persist after multiple attempts to adjust medication or history of a level three hypoglycemic event. 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 pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM)
and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and abutment 
supported crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's tooth was extracted, and an 
implant is required for the mastication process. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 8, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and 
abutment supported crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain crowns (D2740) for tooth #19 and #20. 
 
You asked the Plan to pre-approve the dental services. You say that you badly need these crowns done. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 5, 2022. Therefore, 
we decided that the Plan does not have to pre-approve porcelain crowns (D2740) for tooth #19 and #20.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 24, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 24, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
24, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 24, 2023, forward.  Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 24, 2023, as he 
was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 24, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 24, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has failed conservative 
treatments despite attempting various therapies, including physical therapy, medications, and other 
interventions. The Plan denied your request. The Plan says Intracept procedures are not covered.  
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis. The cause of pain is also not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BluePrint testing provided on June 2, 2023. 
 
You asked the Plan to pay for BluePrint testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this test is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that BluePrint testing is statutorily excluded.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of BluePrint testing have not been met. Therefore, we decided that the Plan does not have to pay for 
BluePrint testing provided on June 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 21, 2023, and billed with codes 874500, 87563, 87591, 87641, 87798, G0452, 87491, 87496, 
87511, 87529, 87532, 87661, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR 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 urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on July 21, 2023, and billed with codes 874500, 87563, 87591, 87641, 87798, G0452, 87491, 
87496, 87511, 87529, 87532, 87661, 87481, 87651, and 87653.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right and left eye blepharoplasty. 
 
You asked the Plan to pre-approve a right and left eye blepharoplasty. You say that the enrollee says that their 
eyelids are droopy and worse. The Plan denied your request. The Plan says there is not a visual improvement 
equal to or greater than 30% with manual lifting of the eye. 
 
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 a right and left eye blepharoplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Visually significant brow ptosis has not been documented by visual field 
testing with the brow elevated demonstrating a difference of 12o or more or 30% superior visual field 
difference. 
 
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 right and left eye blepharoplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a right and left eye blepharoplasty.