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

 
We decided that the Plan does not have to pay for the lab testing billed for date of service January 9, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the test was reasonable and necessary. The Plan 
denied your request. The Plan says the test is not covered. 
 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. The medical records show that a GeneSight Psychotropic test was 
provided. The MolDX program has determined that the reasonable and necessary requirements have not been 
met. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing billed for date of service January 9, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgery services provided from May 22, 2023, to June 14, 2023. 
 
You asked the Plan to pay for the billed services. You say that the surgery was needed. The Plan denied your 
request. The Plan says that an explanation of benefits was not provided. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the file does not show 
that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the bill 
to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the surgery services provided from May 22, 2023, to June 
14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service July 19, 
2023.   
You asked the Plan to pay for procedure code 87634. 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 87634 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87634 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87634 billed for date of service July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system (L5828), an
addition, endoskeletal, stance flexion feature (L5845), an addition to endoskeletal knee-shin system, fluid
stance extension (L5848), a microprocessor control feature (L5856), an above knee or hip disarticulation,
alignable system (L5920), an above knee, knee disarticulation or hip disarticulation, manual lock (L5925) and
an all lower extremity prostheses, flex-walk system (L5981) for the enrollee.

You asked the Plan to pre-approve these items. You say that the enrollee needs a replacement prosthetic. The
Plan denied your request. The Plan says that Medicare Guidance says that the requested computerized knee
advanced feet exceed the enrollee's needs. Maximus overturned the Plan's denial. The Plan requested a
reopening and stated that Maximus did not apply the correct criteria.

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. The Plan noted that the vendor states a K3 prosthetic is medically necessary as the enrollee is a K3
ambulator. However, this is not consistent with available medical history. The medical records show the
enrollee currently use a power wheelchair. This is not consistent with K3 ambulation. Medicare covers items
that meet, but do not exceed, the member's need. The medical records do not show why the enrollee requires a
K3 prosthetic. Therefore, the documentation does not demonstrate that the enrollee is a K3 ambulator.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of these items have been met. There is
inconsistent information in the case file that clearly confirms you meet the required criteria for the requested
prosthetic components. Therefore, we decided that the Plan does not have to pre-approve an addition,
endoskeletal knee-shin system (L5828), an addition, endoskeletal, stance flexion feature (L5845), an addition
to endoskeletal knee-shin system, fluid stance extension (L5848), a microprocessor control feature (L5856), an
above knee or hip disarticulation, alignable system (L5920), an above knee, knee disarticulation or hip
disarticulation, manual lock (L5925) and an all lower extremity prostheses, flex-walk system (L5981) for the
enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation using mechanical device (kyphoplasty) (22515x2). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the medical necessity for the denied procedure/services has 
not been established after clinical review. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation is not evident regarding acute and/or subacute 
fractures at both L3 and L4 levels. Additionally, there is no documentation of a progression of the body height 
loss, greater than 25% vertebral body height loss at both levels, kyphotic deformity, and a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes 
of pain. Therefore, the enrollee does not meet the criteria for coverage and is 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 percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity creation using 
mechanical device (kyphoplasty) (22515x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for continuous glucose monitor (CGM) 
device (A4239) provided June 23, 2023. 
 
You asked the Plan to pay for the supply allowance for CGM device. You say that kindly accept our request 
and reprocess your claim. The Plan denied your request. The Plan says the service/item was provided by a 
supplier that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for continuous 
glucose monitor (CGM) device (A4239) provided June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2023, billed with 
codes 81209, 81223, 81241, 81250, 81305, 81307, 81311, 81320, and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 6, 2023, billed with codes 81209, 81223, 81241, 81250, 81305, 81307, 81311, 81320, and 81334.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig purchased on August 23, 2023.

You asked the Plan to pay for the wig. You say that you believe your state law requires this item to be covered. The Plan denied your request. The Plan says the wig is not covered for two reasons: first, Medicare does not cover wigs. Second, this wig was purchased from a provider who does not participate with Medicare.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.

In addition, the rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider from whom this wig was purchased is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the wig purchased on August 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Unlisted Multianalyte Assay Algorithmic Analysis 
(BluePrint) testing provided on May 22, 2023. 
 
You asked the Plan to pay for the BluePrint testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are specifically not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the BluePrint test is a statutorily excluded test. 
 
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 BluePrint testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Unlisted Multianalyte Assay Algorithmic 
Analysis (BluePrint) testing provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0210) provided on October 16, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had to have x-rays done again because you 
switched dentists and the new office did not get any of your previous records. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 25, 2022, with code 
D0330. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0210) provided on 
October 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room care provided on 
September 06, 2023, to September 08, 2023. 
 
You asked the Plan to waive the copayment for the emergency room care. You say that the dates of service are 
wrong, and you should not have to pay 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 $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for the emergency room care. 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. The Plan confirmed with the medical records department that the dates of service, September 6, 2023, to 
September 8, 2023, were correct. Therefore, we decided that the Plan does not have to waive the copayment for 
the emergency room care provided on September 06, 2023, to September 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each assessment for emotional or 
behavioral problems (96127) provided on June 09, 2023, to August 29, 2023. 
 
You asked the Plan to waive the copayment for each assessment for emotional or behavioral problems (96127). 
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 $25 
copayment for non-radiological diagnostic services. 
 
You have been asked to pay a $25 copayment for each assessment for emotional or behavioral problems 
(96127). This item/service falls within the non-radiological diagnostic 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, the allowed amount is less 
than the copayment, so you only owe $9.80 for each service Therefore, we decided that the Plan does not have 
to waive the copayment for each assessment for emotional or behavioral problems (96127) provided on June 
09, 2023, to August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for Lispro provided on October 14, 2023. 
 
You asked the Plan to reduce the coinsurance for Lispro. You say that you should not be paying this much for 
your insulin that is being used in an insulin pump. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Lispro. This item/service falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $83.16 ($415.80 allowed amount x 20% = $83.16). Therefore, we decided that 
the Plan does not have to reduce the coinsurance for Lispro provided on October 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiograph (ECG) (93000) 
provided on August 22, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiograph (ECG) (93000). 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 $20 
copayment for Outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $20 copayment for the electrocardiograph (ECG) (93000). This item/service falls 
within the Outpatient diagnostic tests and therapeutic services andsupplies 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, the allowed amount is less 
than the copayment, so you only owe $12.81. Therefore, we decided that the Plan does not have to waive the 
copayment for the electrocardiograph (ECG) (93000) provided on August 22, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 
29, 2023. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you had a colonoscopy earlier in 
the year and the prep drink made you sick. 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 $175 
copayment for in-network outpatient surgery at an ambulatory surgical center. 
 
You have been asked to pay a $175 copayment for the colonoscopy. This item/service falls within the in-
network outpatient surgery at an ambulatory surgical center 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 colonoscopy provided on September 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 07, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 the laboratory services 
provided on June 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an expandable controller (E2377) with harness (E2313) and
electronic connection (E2311) for the enrollee.

You asked the Plan to pay for an expandable controller (E2377) with harness (E2313) and electronic
connection (E2311). The Plan denied your request. The Plan says 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 show at the time of the appeal the enrollee had
adequate upper extremity strength to operate the switches that come as standard equipment with a power
wheelchair and the upgrade electronics exceeded the enrollee's needs.

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 available clinical documentation in the case file does not support that the requested expandable controller,
harness, and electronic connection were medically reasonable and necessary for the enrollee in this case.
Therefore, we decided that the Plan does not have to pay for an expandable controller (E2377) with harness
(E2313) and electronic connection (E2311) for the enrollee.