Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on May 24, 2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were not advised by the 
provider of the cost of the coinsurance. 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 the injections. 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 $357.42 ($1,787.10 allowed amount x 20% = $357.42). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the injections provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis that 
requires a Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or  
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with multiple power options (tilt/recline, legrests, seat elevator) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a Freestyle Libre 3 CGM.

You asked the Plan to provide coverage for a Freestyle Libre 3 CGM. The Plan denied your request. The Plan
says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for medical necessity.
The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
Plan's decision was overturned stating that coverage for FreeStyle Libre 3 Sensor is eligible for coverage under
Medicare rules due to PDAC assigning it code E2103. The Plan notes that while the code has been assigned,
not all coverage issues were addressed. The Plan notes that the guidelines state for this type of CGM to be
eligible for coverage under the durable medical equipment (DME) benefit, the CGM must be used in
combination with a reader that is eligible for coverage under DME. Medicare guidelines state a CGM that
solely displays results on a smartphone and does not have a stand-alone receiver (or integration into an insulin
infusion pump) does not meet the definition of DME and will be denied as non-covered. Since the FreeStyle
Libre 3 reader is not currently available in the market, use of the sensor cannot be in combination with a reader
that is eligible for coverage or that is being used with a smart device.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that both non-adjunctive
and adjunctive continuous glucose monitors (CGMs) that solely display results on a smartphone and do not
have a stand-alone receiver or integration into an insulin infusion pump do not meet the definition of DME.

These requests will be denied as non-covered (no benefit). Based on this information, and how this device will
be used, the requested equipment is not covered at this time. Therefore, we decided that the Plan does not have
to provide coverage for a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (21215), reconstruction of mandible or 
maxilla (21249), and anesthesia (00170). 
 
You asked the Plan to pre-approve the dental services. You say that the sooner you have surgery, the sooner 
you can return to normal life. The Plan denied your request. The Plan says the requested services are dental in 
nature. The Plan also says that routine dental services are not covered. 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 
items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a bone graft (21215), reconstruction of mandible or maxilla (21249), and anesthesia 
(00170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided 
December 20, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the surgery was approved, and the 
physician specifically requested that this medically necessary device be dispensed to the enrollee to aid in 
healing at the enrollee's home. The Plan denied your request. The Plan says pneumatic compression device is 
not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve image-guided radiation therapy (IGRT). You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it 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 image-guided radiation therapy (IGRT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that when treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of image-guided radiation therapy (IGRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82306) provided on June 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (82306) provided on June 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on September 28, 2021,
to October 1, 2021, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the
diagnosis codes are documented and clinically valid. The Plan denied your request. The Plan says that
diagnosis codes J15.6 and J96.0 are not supported, which resulted in a DRG change.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with primary
diagnosis code, J15.6, defined as pneumonia due to other Gram-negative bacteria and a secondary diagnosis
code, J96.01, defined as acute respiratory failure with hypoxia. Our Medical Director states that the enrollee
has a medical history that includes heart disease, diabetes, and pulmonary fibrosis. The enrollee presented to
the emergency department on September 28, 2021, with altered mental status, shortness of breath, and left
lower quadrant abdominal pain. Physical examination revealed no tachycardia, and peripheral perfusion was
normal. Respirations were non-labored, and the lungs were clear to auscultation. Normal speech was observed.
A chest X-ray revealed no acute cardiopulmonary process. At the time of admission, the enrollee was in no
acute distress. Vital signs were normal, and the SpO2 was 95% on 4 liters of oxygen. Lungs were clear to
auscultation, and respirations were non-labored. The cardiovascular exam was notable for a normal heart rate
and a regular rhythm. A gram-negative organism was not confirmed. The enrollee was treated with antibiotics.
The available clinical documentation supports that at the time of admission, the downgrading of DRG from 177
(Respiratory infections and inflammations with major complication or comorbidity) to DRG 194 (Simple
pneumonia and pleurisy with complication or comorbidity), with removal of J15.6 and J96.01 was appropriate.
Our Medical Director found that the enrollee's condition did not meet Medicare criteria for the inpatient
hospital services provided from June 29, 2022, to July 2, 2022, at the DRG originally billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided on September 28, 2021, to October 1, 2021, at the Diagnosis Related
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mask liners for a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve mask liners for a CPAP. You say that the requested items are a necessity for 
your care. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that DME is defined as equipment which: 
 
- Can withstand repeated use; i.e., could normally be rented and used by successive patients; 
- Has an expected life of at least 3 years; 
- Is primarily and customarily used to serve a medical purpose; 
- Generally, is not useful to a person in the absence of illness or injury; and, - Is appropriate for use in a patients home. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mask liners for a CPAP have not been met. Specifically, the requested items are disposable items 
that cannot withstand repeated use. The requested items are not eligible for coverage as durable medical 
equipment. Therefore, we decided that the Plan does not have to pre-approve mask liners for a continuous 
positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility follow up visit provided on June 05, 
2023. 
 
You asked the Plan to pay for the nursing facility follow up visit. You say that the 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 nursing facility 
follow up visit provided on June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on June 08, 
2023. 
 
You asked the Plan to pay for the chronic care management services. You say that you are requesting 
reconsideration of the denied claim. 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 chronic care 
management services provided on June 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from June 29, 2022, to
July 2, 2022, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request.
The Plan says that the determination to remove secondary diagnosis code remains upheld.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with secondary
diagnosis code, J96.21 defined as acute and chronic respiratory failure with hypoxia. Our Medical Director
states that the enrollee has medical history that includes chronic obstructive pulmonary disease (COPD), longterm
oxygen use of 2-3 liters, chronic hypoxic respiratory failure, chronic diastolic congestive heart failure, and
active smoking. She presented to the hospital on June 29, 2023, with shortness of breath, and cough that had
been bad for the previous two weeks. The enrollee reported right-sided chest pain with movement. She also
reported she thought her home oxygen compressor was broken. The GM History & Physical dated June 29,
2023, documents that the enrollee was in mild respiratory distress. The respiratory rate was 18, and pulse
oximetry was 98% on 2 liters of oxygen. The physical exam documented generalized rhonchi and expiratory
wheezes; there was no accessory muscle use. A chest X-ray showed right lower lobe atelectasis and/or
pneumonia. The documentation at the time of admission supports the downgrading of DRG from 177
(Respiratory infections and inflammations with major complication or comorbidity) to 178 (Respiratory
infections and inflammations with complication or comorbidity). Our Medical Director found that the enrollee's
condition did not meet Medicare criteria for the inpatient hospital services provided from June 29, 2022, to July
2, 2022, at the DRG originally billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided from June 29, 2022, to July 2, 2022, at the Diagnosis Related Group
(DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Paclitaxel. 
 
You asked the Plan to pre-approve Keytruda and Paclitaxel. You say that the requested drugs are medically 
necessary to treat your diagnosis. The Plan denied your request. The Plan says the requested drugs do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 Keytruda and Paclitaxel. Our reviewer 
says that the requested drugs do not meet the criteria necessary for approval. Our physician reviewer found the 
requested use of Keytruda and Paclitaxel is not FDA-approved for your diagnosis. The use is also not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda and Paclitaxel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda and Paclitaxel.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick (C9399). 
 
You asked the Plan to pre-approve the medication. You say that this drug is medically necessary to treat the 
enrollee. 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 Repatha SureClick (C9399).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on May 9, 2022, to June 7, 
2022. 
 
You asked the Plan to pay for skilled nursing services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says there is no documentation that demonstrates that 
there is a reasonable potential for a future complication or acute episode justify the need for continued skilled 
observation and assessment beyond an initial 3-week period. 
 
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 pay for skilled nursing services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that despite the number of chronic illnesses, including chronic kidney disease, which is noted in records provided, and dementia. There is no condition in the records reviewed that specifically 
required nursing care. The services necessary for this enrollee can be provided by a nursing assistant and there 
were no issues that required the monitoring or services of a nurse. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing services have not been met. Therefore, we decided that the Plan 
does not have to pay for skilled nursing services provided on May 9, 2022, to June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on March 31, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that you are requesting reconsideration of the 
denied claim. 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 telehealth services 
provided on March 31, 2023.