Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair accessory (E1028) provided on May 3, 2023. 
 
You asked the Plan to pay for the wheelchair accessory. You say that the item should be covered. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 11, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the wheelchair accessory have not been met. 
Therefore, we decided that the Plan does not have to pay for the wheelchair accessory (E1028) provided on 
May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on 
June 27, 2023. 
 
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that this should be covered. 
You say that it is medically necessary. You also say that you have submitted everything for reimbursement. 
The Plan denied your request. The Plan says the provider in this case is not eligible to participate in Medicare. 
The Plan also says that payment cannot be made to a provider that is not eligible to participate in 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 reimburse you for the portable oxygen 
concentrator purchased on June 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
June 21, 2023, to June 30, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel the Plan 
should pay more towards the bill. 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 $375 
copayment per day, for days 1 to 5 for in-network inpatient hospital care. There is a $0 copayment for day 6 
and beyond. 
 You have been asked to pay a total of $1,875, which is a $375 copayment per day for days one to five of the 
inpatient hospital stay. You have not been asked to pay for days beyond day five. This item/service falls within 
the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided from June 21, 2023, to June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve.  
 
You asked the Plan to pre-approve the intraosseous ablation of the basivertebral nerve. You say that the 
enrollee's primary problem is chronic low back pain due to degenerative disc disease that has resulted in the 
development of vertebrogenic pain identified by degenerative endplate changes frequently know by eponym 
modic on their magnetic resonance imaging (MRI). The Plan denied your request. The Plan says the 
intraosseous ablation of the basivertebral nerve 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 the intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the intraosseous ablation of the basivertebral nerve is not medically 
necessary. Our physician reviewer found that there is no MRI showing only modic changes without facet 
degenerative joint disease or stenosis, and the cause of 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 the intraosseous ablation of the basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral 
nerve.
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 completion of inpatient acute rehabilitation will 
help avert unplanned readmission to an acute care hospital and ensure a safe discharge home where the enrollee 
may continue recovery with home health and transition to a neuro outpatient program. The Plan denied your 
request. The Plan says the enrollee's condition does not meet all the requirements for inpatient rehabilitation 
admission. The Plan says services may be provided at 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. The medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81456 billed for date of service July 21, 2023. 
 
You asked the Plan to pay for the billed code. You say that the documentation supports medical necessity. The 
Plan denied your request. The Plan says that codes 81455 and 81456 are mutually exclusive. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied code 81456 as it cannot be billed with code 81455. The 
Plan has not provided documentation to show that these two codes were billed on the same date by the provider 
at issue. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for procedure 
code 81456 billed for date of service July 21, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the IRF care is necessary for the enrollee's ability to
regain his maximum function. The Plan denied your request. The Plan says that the IRF care is not medically
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility.
Maximus overturned the Plan's denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The records
clearly show that at the time of the appeal prior to admission the enrollee did not meet all the criteria required
by Medicare for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing billed with code 81433 for date of service 
July 26, 2023. 
 
You asked the Plan to pay for the genetic testing billed with code 81433. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays 2 or more genes in a patient 
in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so 1 HCPCS codes must be submitted for the panel. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue were a panel. The 
Plan approved/paid one code; however, a second code is considered unbundled and therefore, not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
with code 81433 have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing billed with code 81433 for date of service July 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
November 11, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $160 
copayment for outpatient diagnostic test/radiological d diagnostic services, including ultrasounds. 
 
You have been asked to pay a $160 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test/radiological d diagnostic services, including ultrasounds 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, since the 
allowed amount is less than the standard copayment, you only owe $76.75. Therefore, we decided that the Plan 
does not have to waive the copayment for an outpatient diagnostic test provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Leuprolide injection services provided on August 23, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the Leuprolide injection services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the Leuprolide injection services provided on 
August 23, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external transmitter (A9277). 
 
You asked the Plan to pre-approve A9277. You say that this is just a software update. The Plan denied your 
request. The Plan says the requested service is noy a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that A9277 is not a covered benefit. 
 
We looked at the file and Medicare rules. A9277 is not a covered benefit. Based on this information, we 
decided that Medicare rules for coverage of A9277 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an external transmitter (A9277).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on November 
01, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that the copayment should be a 
different amount since it was one sess 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 outpatient rehabilitation services. 
 
You have been asked to pay a $50 copayment for physical therapy. This item/service falls within the outpatient rehabilitation 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. You have been ask to pay a total of $50 for a physical therapy visit on November 11, 
2023. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided 
on November 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on July 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the duplex scan. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the duplex scan provided on July 13, 2023, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 17, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should have a $0 copayment 
for the service you received. 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 other outpatient diagnostic tests - radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $175 copayment for the ultrasound. This item/service falls within the other outpatient diagnostic tests - radiological diagnostic services, not including x-rays 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, since the allowed amount is 
less than the standard copayment, you only owe $97.36. Therefore, we decided that the Plan does not have to 
waive the copayment for the ultrasound provided on August 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 28, 
2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307. 
 
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 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound care supplies (A6197, A6446, 
A6216, A4452) provided on July 31, 2023. 
 
You asked the Plan to waive the coinsurance for the wound care supplies (A6197, A6446, A6216, A4452). 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 15% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 15% coinsurance for the wound care supplies (A6197, A6446, A6216, A4452). 
This item/service falls within the durable medical equipment (DME) and related 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 waive the coinsurance for the wound care supplies (A6197, A6446, A6216, A4452) 
provided on July 31, 2023.