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

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the electrocardiogram is normal and a treadmill stress test in August 2023, was 
negative for ischemia. The medical records provided do not support the rationale for this invasive imaging 
study. Guidelines do not support a need for cardiac catheterization in this 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires daily physician oversight from 
oncology, neurology, pulmonary and adjust medication as needed. The Plan denied your request. The Plan says 
the enrollee's records do not show that the rehabilitation needs are complex. The Plan says that the services 
needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a warranty purchased on July 7, 2022.
You asked the Plan to reimburse you for this warranty. You say that you believe the Plan should reimburse you
for the warranty for this equipment. The Plan denied your request. The Plan says this type of purchase is not
covered by Medicare. Maximus overturned the Plans denial for insufficient information in the case file
regarding the denial. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that for equipment to be
covered, it must primarily serve a medical purpose. Medicare does not cover the purchase of a warranty for
oxygen equipment as it typically is a rented item to be covered by Medicare. The purchase of a warranty is
precautionary and is not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse
you for a warranty purchased for oxygen equipment on July 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's records 
do not show the need for an intensive team for care. The Plan says that the services needed may be provided 
safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated shoulder orthosis (L3960).
You asked the Plan to pay for this orthosis. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans
denial for insufficient information in the case file. The Plan requested a reopen and noted the claim shows the
diagnosis to be M25.551, pain in the right shoulder. The medical records submitted show no reported issues
with the right shoulder. The diagnosis code for the office visit was I87.2 for venous insufficiency and I77.81
for aortic ectasis, abdominal. Diagnostics were ordered for these reported diagnosis codes and compression
stockings were ordered. There is no mention in the medical records of issues with the right shoulder needing an
orthosis.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. The medical records provided do not support
the services billed for this orthosis. Therefore, we decided that the Plan does not have to pay for a prefabricated
shoulder (L3960) orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the current physical and occupational deficits, along 
with comorbidities, we have determined the enrollee requires and would benefit -from intensive inpatient rehab 
hospitalization with daily physician visits and examinations. The Plan denied your request. The Plan says the 
enrollee's medical conditions have stabilized, and records do not show the need for intensive services 
consisting of 3 hours of daily therapies for rehabilitation. The Plan says that the services needed may be 
provided safely in a lower level of care. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on September 20,
2022.
You asked the Plan to pay for the genetic testing. You say that these services were medically necessary. The
Plan denied your request. The Plan says that the claim was not billed with the appropriate DEX Z-code.
Maximus overturned the Plans denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the
DEX Z-Code Z00D5 coverage status shows as "Not Covered" for Medicare billing. The Plan included the
registry page that confirms this.
The Plan is correct 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 code. In this case the reported
DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for
the genetic testing provided to the enrollee on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313) and 
push handles (K0108) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and push handles. You say that these items should 
be approved.  The Plan denied your request. The Plan says the denied items do not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. This extends to items that are considered duplicative. 
 
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 expandable controller and push 
handles. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has sufficient strength and function in upper extremities to 
manage standard power drives through their individual switches. 
 
We have also determined that push handles are duplicative to the enrollee-operated drive control and cannot be 
separately covered by Medicare. 
 
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 expandable controller and push handles have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313) and push 
handles (K0108) for an approved power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 degenerative joint disease (DJD) or foraminal stenosis. The cause of the pain is 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 (64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet all the requirements. The Plan says that 
the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q9967 rendered on December 19, 2022. 
 
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 Current Procedural Terminology (CPT) code Q9967 (1 units) remains not supported. 
 
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 Q9967 is "Low osmolar contrast material, 300-399 
mg/ml iodine concentration, per ml." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee had a computed 
tomography (CT) scan of the chest, abdomen, and pelvis, with iodinated contrast on December 16, 2022. Neither the type of contrast nor the volume of contrast used was documented in the report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code Q9967 rendered on December 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound provided on April 18, 2023. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you were not told that you would 
have a remaining balance after your $20 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 $95 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $95 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 reduce the 
copayment for an ultrasound provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hereditary Cancer Panel testing and breast cancer gene 
(BRCA) testing (81432, 81433). 
 
You asked the Plan to pre-approve Hereditary Cancer Panel testing and BRCA testing. You say that the 
requested service is a prerequisite to have surgery. You would like to get this testing approved. The Plan denied 
your request. The Plan says you do not meet criteria for approval of the requested genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the NCD is only applicable to diagnostic lab tests 
using NGS for somatic (acquired) and germline (inherited) cancer.  
 
We looked at the file and Medicare rules. Medicare rules say that the requirement for the requested testing is 
that you have a personal history of breast, ovarian or pancreatic cancer. The records show you do not have any 
signs or symptoms of cancer; therefore, the test is considered solely for screening purposes and Medicare does 
not cover this test for screening purposes. Based on this information, we decided that Medicare rules for 
coverage of Hereditary Cancer Panel testing and BRCA testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Hereditary Cancer Panel testing and breast cancer gene (BRCA) testing 
(81432, 81433).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cardiovascular stress test provided on 
May 05, 2023. 
 
You asked the Plan to reduce the copayment for a cardiovascular stress test. You say that you were quoted a $5 
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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $220 copayment for a cardiovascular stress test. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies 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 reduce the copayment for a cardiovascular stress test provided on May 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 07, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not receive 
services on this date. 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 $35 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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. The medical records show you were seen by a specialist on 
February 7, 2023. Therefore, we decided that the Plan does not have to waive the copayment for the specialist 
office visit provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on August 02, 
2022, to September 01, 2022. 
 
You asked the Plan to waive the copayment for podiatry 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 $30 
copayment for podiatry services. 
 
You have been asked to pay a $30 copayment for podiatry services. This item/service falls within the podiatry 
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. The total amount you are being asked to pay is $120 ($30 x 4 visits = $120). Therefore, we decided that 
the Plan does not have to waive the copayment for podiatry services provided on August 02, 2022, to 
September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 2, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that there are no network providers who perform 
this service. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. 
The Plan also says that payment cannot be made for services performed by a provider that has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Additionally, the file shows that you signed a financial agreement 
indicating that you accept full responsibility for payment of the service performed by this provider. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on May 2, 2023.