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

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 5, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) for palpitations. The records support an 
appropriate history and physical were obtained; However, a standard work-up was performed and the medical 
decision making was not of high complexity. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on July 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro (J3490). 
 
You asked the Plan to pre-approve the medication. 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 Mounjaro (J3490).   
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The review has 
determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 28, 2023, billed with 
procedure code 49329-AS. 
 
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, the CPT Code Manual definition of code 49329-AS is unlisted laparoscopy procedure, abdomen, 
peritoneum and omentum. 
 
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 procedure in question was not 
coded to the highest specificity, an unlisted code is not appropriate in this case. 
 
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 March 28, 2023, billed with procedure code 
49329-AS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 11, 2023, billed 
with procedure codes 10160-78-RT and 99213-24. 
 
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 codes. 
 
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 codes 10160-78-RT and 99213-24 is puncture aspiration of 
abscess, hematoma, bulla, or cyst, and office or other outpatient visit for the evaluation and management of an 
established patient, which requires a medically appropriate history and/or examination and low level of medical 
decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the 
encounter.  
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 codes. Our reviewer found that the enrollee had a minor procedure 
(10160) performed on August 11, 2023. CPT 10160 has a 10-day global period; therefore CPT 99213 is 
included in code 10160. The submitted documentation does not include sufficient documentation to validate the 
use of a modifier to unbundle these services. 
 
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 August 11, 2023, billed with procedure 
codes 10160-78-RT and 99213-24.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says that the Medicare coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was met. Our physician reviewer found that there is a note that saying the enrollee 
meets the hypoglycemic characterization criteria. In addition, the enrollee is unable to use a fingerstick meter 
due to tremors. Using Glipizide and having an A1c of 5.6, the enrollee likely is having low blood sugars. 
Hence, it is reasonable to approve the CGM for this enrollee. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
  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: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for out of network laboratory services provided on May 26, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says you did not have
prior authorization for out of network services. Maximus overturned the Plans denial for insufficient
information in the case file. The Plan requested a reopen and provided the required information. The Plan
confirmed the lab services were also ordered by an out of network provider without prior authorization.

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. Both providers in this case were out of network. The Plan had
network providers available who could have provided the items/services at issue in this appeal. The Plan did
not pre-approve the item/service at issue.

We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that
the Plan does not have to pay for out of network laboratory services provided on May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hernia repair (49505) provided on 
September 12, 2023. 
 
You asked the Plan to waive the copayment for the hernia repair (49505). You say that the cost share is wrong. 
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 $450 
copayment for outpatient surgery. 
 
You have been asked to pay a $450 copayment for the hernia repair (49505). This item/service falls within the 
outpatient surgery 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. This service was obtained out-of-network, therefore you are responsible fora  $450 copayment. 
Therefore, we decided that the Plan does not have to waive the copayment for the hernia repair (49505) 
provided on September 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 3 sensor. You say that you are trying to use this to 
prevent from being on insulin which you believe will be costly. You also say that you are trying Mounjaro 
currently and are trying to figure out why your levels are up and down. The Plan denied your request. The Plan 
says you do not meet criteria for the FreeStyle Libre 3 sensor. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre 3 sensor. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found coverage criteria for 
CGM require insulin use or low blood glucose sugar. You are not having low blood glucose sugar we are told 
of and are not using insulin though one of the notes say that you may need it. We are not told why you cannot 
check your blood glucose sugar with a meter and why a CGM is needed. Although a CGM may help you, 
criteria coverage is not met. 
 
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 Freestyle Libre 3 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 3 sensor.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the core buildup (D2950) for tooth #7, #8, #9, and #11 provided on 
June 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that the core buildup should be covered under there 
dental benefits. The Plan denied your request. The Plan says that the denial of payment for these services is 
correct, because the services did not meet the criteria for benefits. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says that 
the core buildup (D2950) for tooth #7, #8, #9, and #11 is medically necessary. Our physician reviewer found 
that the documentation indicates that teeth #7, #8, and #9 have multi-surface caries and tooth #11 has a 
defective restoration. The caries and defective restoration must be removed prior to crown placement. The core 
build up is medically reasonable and necessary to provide adequate retention and stability for the crowns. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pay for the core buildup (D2950) for tooth #7, #8, #9, and #11 provided on June 30, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 64488 rendered on July 19, 
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 only one unit of CPT 64488 should be reported for one date of service for a single patient 
encounter. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure report documents a bilateral transversus abdominis plane (TAP) block was performed with ultrasound guidance. In this case, one unit should have been reported with the bilateral modifier. The additional 
unit billed is not verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 64488 rendered on July 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services on June 30, 
2023.  
 
You asked the Plan to waive the copayment for the emergency room services. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for Medicare covered emergency room visits. 
 
 
 
 You have been asked to pay a $120 copayment for the emergency room services. This item/service falls within 
the emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
services on June 30, 2023.
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 the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says when the enrollee is ready 
to leave the hospital, they can receive their care in another setting.  
 
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 is not stable for transfer to LTACH at this time and is receiving the 
needed care in their current setting. There is no therapeutic advantage to transfer to an LTACH. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132, 96136). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the service can not be approved using the requested codes. 
 
The Plan must follow Medicare rules. Medicare rules say that for automated testing and results for 
psychological or neuropsychological testing, providers must use code 96146. 
 
We looked at the file and Medicare rules. The requested Braincheck test is computerized testing that must be 
reported using code 96146. Based on this information, we decided that Medicare rules for coverage of 
neuropsychological testing have not been met. Please note that the plan has stated that the service can be 
covered if submitted using the appropriate code. Therefore, we decided that the Plan does not have to pre-
approve neuropsychological testing (96132, 96136).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Abrysvo vaccine. 
 
You asked the Plan to pre-approve Abrysvo. You say that this vaccine would greatly benefit the enrollee and 
prevent complications. The Plan denied your request. The Plan says this immunization is not among those 
covered by Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Abrysvo. The Plan 
follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Abrysvo. 
Therefore, we decided that the Plan does not have to pre-approve the Abrysvo vaccine.  
 
Benefits for Abrysvo 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
on August 15, 2023. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you should only 
be charged an emergency room 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 $350 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $350 copayment for the hospital observation services. This item/service falls 
within the 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 waive the copayment 
for the hospital observation services provided on August 15, 2023.