Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the associated administration of the Part B drug. We 
decided that the Plan does not have to reduce the coinsurance for a Medicare Part B drug injection.  
 
You asked the Plan to reduce the coinsurance for a Medicare Part B drug injection and the associated 
administration of the drug provided on July 20, 2023. You say that you have been told different cost share 
amounts, and you disagree with the coinsurance applied. The Plan says that this cost sharing was charged 
correctly. 
 
We decided that the Plan has to waive the coinsurance for the associated administration of the Part B 
drug.  
 
The rules say a health 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 states that there is no 
additional cost for the administration of Part B drugs. The Plan charged you $27.58 for the drug administration 
performed on July 20, 2023. Therefore, we decided that the Plan has to waive the coinsurance for the 
associated administration of the Part B drug. 
 
We also decided that the Plan does not have to reduce the coinsurance for a Medicare Part B drug 
injection. 
 
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 a Medicare Part B drug injection. You have been asked to pay $472.80, which is 20% of the 
allowed amount for a Medicare Part B drug injection ($2,364 allowed x 20% coin = $472.80). Therefore, we 
decided that the Plan does not have to reduce the coinsurance for a Medicare Part B drug injection. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure monitor (A4670). 
 You asked the Plan to pre-approve a blood pressure monitor. You say that you have chronic hypertension, and 
the monitor is necessary due to aspiration. The Plan denied your request. The Plan says you do not meet criteria 
for approval of a blood pressure monitor. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor (A4670).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are necessary for 
your recovery. The Plan denied your request. The Plan says the additional PT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have been receiving PT since March 24, 2023. Your progress 
with range of motion and motor strength has stabilized and is within functional limits. You do not have 
significant functional deficits with regards to performing daily activities. Additional progress with range of 
motion and strength can be accomplished in the context of a home exercise program and does not require the 
services of a skilled therapist. Therefore, the 10 additional PT visits are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from July 3, 2023, to July 27, 
2023. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this claim does not include the required Q- code.  
The Plan must follow Medicare rules. Medicare rules say that a home health agency must report the location 
where services were performed using one unit of code Q5001, Q5002, or Q5009 with a nominal charge.  
 
We looked at the file and Medicare rules. This claim does not include the required Q- code to report the 
location where services were performed. Based on this information, we decided that Medicare rules for 
coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pay for 
home health care provided from July 3, 2023, to July 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (27252) provided on June 13, 2023. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 27252 is not supported in the medical record. Specifically, the claim was billed with 
modifier 78, however the records do not show an unplanned returned to the operating room. Based on this 
information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, 
we decided that the Plan does not have to pay for surgical services (27252) provided on June 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  the Dexamethasone Sodium Phosphate, 
Diphenhydramine Hcl, Palonosetron Hcl, and Mirvetuximab Soravtansine-Gynx provided on July 27, 2023. 
 
You asked the Plan to waive the coinsurance for  the Dexamethasone Sodium Phosphate, Diphenhydramine 
Hcl, Palonosetron Hcl, and Mirvetuximab Soravtansine-Gynx. You say that you should not be responsible to 
pay this. 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% 
coinsurance for Part B chemotherapy.  
 
You have been asked to pay a $0.29 for the Dexamethasone Sodium Phosphate ($1.44 x 20% = $0.29). You 
been asked to pay $0.21 for Diphenhydramine Hcl ($1.06 x 20% = $0.21). You have been asked to pay $2.00 for Palonosetron Hcl ($10.00 x 20% = $2.00). You have been asked to pay $2,615.18 for the Mirvetuximab 
Soravtansine-Gynx. Please note you this is less than the required 20% coinsurance because your out-of-pocket 
maximum had been met. The amount you owe is $2617.68 ($0.29 + $0.21 + $2.00 + $2,615.18 +2,617.68).  
These items/services fall within the Part B chemotherapy 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 Dexamethasone Sodium Phosphate, Diphenhydramine Hcl, Palonosetron Hcl, 
and Mirvetuximab Soravtansine-Gynx provided on July 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivaer procedure. 
 
You asked the Plan to pre-approve the Vivaer procedure. You say that the supplied medical records support 
authorization of this service. The Plan denied your request. The Plan says the enrollee has been approved for 
septoplasty. However, the requested Vivaer procedure is considered an investigational treatment at this time. 
There is not enough evidence to show that this procedure is safe and effective. 
 
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 the Vivaer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has nasal obstruction from a deviated septum and rhinorrhea.  There is 
insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific 
conditions.  The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. 
 
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 Vivaer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vivaer procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing 
provided on May 4, 2023. 
 
You asked the Plan to pay for urine PCR panel. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this test panel should have been as a single unit of service. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular syndromic panels for infectious 
disease testing must be billed with 1 unit of service of their proprietary procedure code, or if there is no 
proprietary procedure code then 1 unit of 87999 with the appropriate Z-Code for the test. 
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of urine PCR panel have not been met. Therefore, we 
decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing provided on 
May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for code (99291) provided to the enrollee on November 14, 
2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan 
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned 
the Plans denial for insufficient claim information in the file. The Plan requested a reopen and 
submitted the missing claim information. The Plan noted that claim number 56304227-00 is being 
appealed as claim for recoupment of the global days for date of service (DOS) November 14, 2022. 
This claim was recouped on paid date December 08, 2022; however, it was then resubmitted under 
claim 56304228-00 which was then paid again on December 08, 2022. The Plan states they also found a 
claim billed for code 93456 which has "00" global days with modifier 25 not billed under claim 
number 56358341-00 also for DOS November 14, 2022, with the TIN 464354068.

The Plan notes that surgery procedure code 93456 is a minor procedure that has a global surgery 
period of "0" days. Payment for code 99291 is included when billed the same day as minor surgery 
code 93456, without an appropriate modifier. The Plan noted that the two billing providers have the 
same TIN and Taxonomy number and are both listed under Interventional Cardiology, Internal 
Medicine, which is also the same TIN number as the facility. As a result, claim number 56358341-00 
for code 93456 was submitted and claim number 56304228-00 for code 99291 was billed for the same 
DOS, November 14, 2022, which is denied due to the Medicare guidelines over these being bundled 
codes.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that 
providers must report services correctly. In this case, this claim could not be paid as billed due 
to its bundled relationship with other codes billed for the same date of service for the same 
enrollee and billed by the same provider group.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not
have to pay for code (99291) billed on a second claim to the enrollee for November 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93623 billed for date of service July 11, 2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says that the billed 
code cannot be verified. 
 
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 93623 is an add-on code that has been billed with an appropriate 
primary procedure code, 93656. Based on this information, we decided that Medicare rules for coverage of the 
billed service have been met. Therefore, we decided that the Plan has to pay for procedure code 93623 billed 
for date of service July 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2. You say that the enrollee's A1C is high and she is on 
diabetic medications. You also say that the enrollee is unable to tolerate Metformin. The Plan denied your 
request. The Plan says there were no medical records documentation that shows the enrollee is treated with 
insulin or has had hypoglycemia.  
 
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 2. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by Medicare rules. The elements of coverage are not satisfied. 
 
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 2 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Libre 2.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 billed for date of service July 7, 2023. 
 
You asked the Plan to pay for the billed service. You say that the code edits were removed. The Plan denied 
your request. The Plan says that there are no modifiers allowed with this code pair. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code G0482 is supported. The claim shows that code G0482 was billed with code 80307. 
CMS withdrew these edits retroactive to July 1, 2023, in a replacement file for the 4th quarter of 2023. Plans 
will adjust claims with dates of service between July 1, 2023, and October 1, 2023, to allow payment as 
appropriate under existing payment and coverage policies. Based on this information, we decided that 
Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0482 billed for date of service July 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer with compression (E0570) purchased on July 
26, 2023, from a non-Medicare certified provider. 
 
You asked the Plan to pay for the nebulizer. You say that you would like to appeal this denial. The Plan denied 
your request. The Plan says the provider you purchased the nebulizer from is not listed to be an acceptable 
provider for the member. The Plan also says they found multiple certified providers within 10 miles of your zip 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nebulizer have not been met. The rendering provider is not part of the Medicare program and is 
not payable. Therefore, we decided that the Plan does not have to pay for the nebulizer with compression 
(E0570) purchased on July 26, 2023, from a non-Medicare certified provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee needs this device 
immediately. You say that the enrollee does not currently have the device, which helps prevent pulmonary 
infections, hospitalizations, or the need for antibiotics. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. However, 
there is no documentation of trial and failure of a BiPAP device with AVAPS and a back-up rate. Also, the 
records in this case do not provide adequate detailed information to meet the Medicare criteria for coverage for 
a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve PuraPly and Apligraf skin substitutions. You asked the Plan to pre-approve PuraPly and Apligraf. You say that skin grafting will help assist with the 
healing process of an open diabetic ulcer. The Plan denied your request. The Plan says that the request does not 
meet requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that skin substitutes may be covered when certain 
conditions 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 PuraPly and Apligraf. Our reviewer 
says that you meet medical necessity criteria for this service. Our physician reviewer found you have a covered 
wound type, which has failed to respond to standard wound management. There is documentation 
demonstrating which therapies have failed and why. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PuraPly and Apligraf have been met. Therefore, we decided that the Plan has to 
pre-approve PuraPly and Apligraf skin substitutions.  
 
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.