Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a multiaxial ankle with swing phase feature
(L5968) and flex-walk system (L5981) for the enrollee.

You asked the Plan to provide coverage for this prosthetic equipment. You say that at the time of the appeal,
this prosthetic equipment was medically necessary.

The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned
the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The
Plan noted that the medical records do not show the enrollee is a K3 ambulator. While the physician notes
indicate K3 ambulation, the medical record does not corroborate this. At the time of the appeal, the enrollee
was ambulating with a cane and a prosthesis. The enrollee has a knee flexion contracture. None of this clinical
information supports K3 functional ambulation.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Based on the medical records provided, the enrollee does not meet the criteria
required for the requested prosthetic equipment. Therefore, we decided that the Plan does not have to provide
coverage for a multiaxial ankle with swing phase feature (L5968) and flex-walk system (L5981) for the
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the humidifier (E0562) provided on June 4, 2023. 
 
You asked the Plan to pay for the humidifier. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the humidifier (E0562) provided on June 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64415 billed for date of service February 28, 
2023. 
 You asked the Plan to pay for procedure code 64415. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 64415 is bundled into payment for code 01638. 
 
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 64415 
is a column II code to column I code 01638. 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 64415 billed for date of service February 28, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 24, 
2023, to August 16, 2023. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
copayment. 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 $10 
copayment for outpatient diagnostic test/laboratory services. 
 
You have been asked to pay a $10 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic test/laboratory 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. However, since the allowed amount is less than the standard copayment, 
you only owe $9.92 per visit. The total amount you are being asked to pay is $39.68 ($9.92 x 4 visits = $39.68). 
Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on 
July 24, 2023, to August 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
05, 2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with th 
copayment. 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 $220 
copayment for ambulance services. 
 
You have been asked to pay a $220 copayment for ambulance services. This item/service falls within the 
ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on October 05, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that continued care is medically necessary. The Plan 
denied your request. The Plan says the documentation states that the enrollee is independent with all activities 
of daily living, ambulation, toileting and is not nursing home level appropriate at this time.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service April 19, 2023. 
 
You asked the Plan to pay for the laboratory services billed with code 81479. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
billed with code 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 81479 for date of service April 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service July 7, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 97010 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service July 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $55 copayment charged for an ultrasound provided on
September 22, 2022.

You asked the Plan to waive this copayment. You say that you did not receive this service. The Plan denied
your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial for a
lack of medical records in the file. The Plan requested a reopen and submitted medical records to show you did
indeed have this service.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). 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 $55 copayment charged for an ultrasound
provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM) and
supply allowance for the enrollee.

You asked the Plan to provide coverage for a continuous glucose monitor (CGM) and supply allowance. You
say that at the time of the appeal, this device was medically necessary. The Plan denied your request. The Plan
says the required coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at
least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose
testing results and have had an in-person visit with their treating physician to assess adherence to their CGM
regimen and diabetes treatment plan.

Based on the medical records provided, the enrollee does not meet all of the criteria listed above. Therefore, we
decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM) and supply
allowance for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 31, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that this service is supported in the records. 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 psychotherapy provided 
on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service August 8, 
2022.  
 
You asked the Plan to pay for procedure code 95861. You say that the code is separately reportable. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were separate and distinct 
and actually provided. Based on this information, we decided that Medicare rules for coverage of procedure 
code 95861 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
95861 billed for date of service August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Freestyle Libre 3 and supply allowance for
the enrollee.

You asked the Plan to provide coverage for a Freestyle Libre 3 and supply allowance. You say that this device
is medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of device and supply allowance. Based on the records provided, the enrollee is solely using a
smartphone for CGM display glucose data. In this case the Freestyle Libre 3 and supply allowance is not
covered by Medicare. Therefore, we decided that the Plan does not have to provide coverage for a Freestyle
Libre 3 and supply allowance for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 20, 2022, billed 
with procedure code 64415-59. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 64415-59 is a column II code to column I code 01630; however, 
64415-59 was billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical record does not include 
sufficient documentation to support that the nerve block was requested by the surgeon for post op pain. 
Documentation supports injection was given prior to anesthesia start time, however documentation does not 
support criteria for post op pain management. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 20, 2022, billed with procedure 
code 64415-59.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98960 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for procedure code 98960. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 98960 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 98960 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 98960 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 98960 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 98960 billed for date of service July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on September 
05, 2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records proving medical necessity. 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 office visit and 
related services provided on September 05, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on May 25, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the transport method was medically 
necessary. The Plan denied your request. The Plan says there is insufficient information to determine medical 
necessity of the provided services. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the air ambulance services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found the documentation does not 
support that the patient's condition was such that the time needed to transport a patient by ground, or the 
instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the 
patient's health. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on August 03, 2023. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that the services should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic 
visit provided on August 03, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 11, 
2023, to June 30, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $195 
copayment for inpatient hospital care. 
 
You have been asked to pay a $195 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The total amount you owe is $1,170 ($195 x 6 days = $1,170). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on June 11, 2023, to June 
30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on June 21, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-SCC testing is not covered. 
 
We looked at the file and Medicare rules. The testing at issue is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on June 21, 
2023.