Persius/hicric huggingface dataset:
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 you need the level of care provided in an IRF. The 
Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable, and there are no complex nursing or rehabilitation needs. Medically necessary services can be 
provided in a lower level of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) provided on June 15, 2023, and June 19, 2023. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that you spoke to the provider's 
office and were told they would send another claim to the plan. You also say that if it makes any difference, the 
dates you are appealing are June 15, 2023 and June 19, 2023 not June 15, 2023 only. The Plan denied your 
request. The Plan says the services provided are not a covered benefit under your dental plan. 
 
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, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) provided on June 15, 2023, and June 19, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service August 22, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing can assist in making treatment 
decisions. The Plan denied your request. The Plan says the testing 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. Although the claim does list a unique identifier, the test has been 
assessed and shown to be not covered. Based on this information, we decided that Medicare rules for coverage 
of the billed testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing billed for date of service August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an Ottobock Trias Prosthetic foot (L5981,
L5986) for the enrollee.

You asked the Plan to provide coverage for the requested prosthesis. The Plan denied your request. The Plan
says the 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 from
the physician make no mention of the need for a K3 prosthetic foot. There were no medical reasons given as to
why a K2 foot would not meet the enrollees needs. The medical records do show the enrollee uses a walker and
wheelchair, which is not consistent with a K3 ambulator.

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. 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 the requested prosthesis have been met. Therefore, we decided that the Plan does not have
to provide coverage for an Ottobock Trias Prosthetic foot (L5981, L5986) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a microprocessor-controlled ankle foot system
(L5973) for the enrollee.

You asked the Plan to provide coverage for a microprocessor-controlled ankle foot system (L5973). The Plan
denied your request. The Plan says the 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
the medical records show the enrollee uses oxygen and lives in an independent living facility. The enrollee is
shown to use a walker full time and a wheelchair at night. This indicates that enrollee is a K2 ambulator. There
are no medical records that show a K3 mechanical foot will not meet member's needs. The medical records do
not show the enrollee has advanced to K3 ambulatory function.

The Plan is correct in this case. 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. 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 a
microprocessor-controlled ankle foot system (L5973) have been met. Therefore, we decided that the Plan does
not have to provide coverage for a microprocessor-controlled ankle foot system (L5973) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is necessary because the enrollee cannot 
pinch their finger twice a day. The Plan denied your request. The Plan says the Medicare coverage criteria was 
not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the enrollee is noted to have diabetes. 
There is no evidence that the enrollee uses insulin. There is no evidence that the enrollee has problems with 
recurrent or severe hypoglycemia. As such, the requested CGM is not shown to be medically necessary, 
reasonable or coverable. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 09, 2023, to July 05, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was 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 drug testing 
provided on May 09, 2023, to July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 7, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this was medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit (99214) provided on August 7, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller with harness and
electronic connection upgrade for a power wheelchair approved by the Plan for the enrollee.

You asked the Plan to provide coverage for the requested upgraded electronics. The Plan denied your request.
The Plan says the Medicare coverage criteria were not met at the time of the appeal. 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 the enrollee has adequate upper extremity strength to operate the standard
switches that come with the power wheelchair approved by the Plan. The medical records do not indicate why
the enrollee would require upgraded electronics for the approved power wheelchair.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. 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. The notes do not show the medical necessity of
controlling the power options through a joystick. Therefore, we decided that the Plan does not have to provide
coverage for an expandable controller with harness and electronic connection upgrade for a power wheelchair
approved by the Plan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on August 10, 2022, to 
August 17, 2022. 
 You asked the Plan to pay for the wound care services. You say that you are requesting reconsideration of the 
denied services. 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 wound care services 
provided on August 10, 2022, to August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a microprocessor knee with positional
rotation unit (L5828, L5845, L5848, L5850, L5856, L5925, K1022) and adjustable heel height (L5990) for the
enrollee.

You asked the Plan to provide coverage for this request. The Plan denied your request. The Plan says the
Medicare coverage criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria. The Plan noted the medical records do not
reflect the enrollee is a K3 ambulator. The medical records do not explain why a microprocessor knee is needed
over a K3 mechanical knee.

The Plan is correct in this case. 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. 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 this
request have been met. Therefore, we decided that the Plan does not have to provide coverage for a
microprocessor knee with positional rotation unit (L5828, L5845, L5848, L5850, L5856, L5925, K1022) and
adjustable heel height (L5990) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs the replacement. The 
Plan denied your request. The Plan says the enrollee's 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's benefit for the requested item or service was exhausted on date of service July 7, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675). 
 
You asked the Plan to pre-approve a pneumatic compression device. The Plan denied your request. The Plan 
says the pneumatic compression device requested does not meet the requirements for approval. 
 
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 
pre-approve a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service June 8, 2023. 
 
You asked the Plan to pay for procedure code 87801. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87801 is bundled into 
payment for code 87631. 
 
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 87801 
is a column II code to column I code 87631. 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 87801 billed for date of service June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 81279 provided on May 24, 
2023. 
 
You asked the Plan to pay for the lab services billed with code 81279. You say that you disagree with the Plan's 
denial. 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 billed with code 81279 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 billed with code 81279 provided on 
May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on August 31, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the service should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit (99215) provided on August 31, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) provided on 
August 16, 2023. 
 
You asked the Plan to pay for the annual wellness visit. You say that you had this appointment before. You say 
that you do not understand why they made you get a second examination. You also say that you feel this charge 
should be waived since you were not properly informed. The Plan denied your request. The Plan says the 
benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) 
provided on August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on June 16, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS only recognizes twelve (12) Drug 
Class/Drugs (Alcohol/Alcohol Metabolites; Barbiturates; Benzodiazepines; Illicit Drugs; Synthetic 
Cannabinoids; Cathinones; General Anesthetics, Muscle Relaxants; Neuroleptics; Opiates; Opioids; and 
Stimulants). Since HCPCS code G0482 represents testing 15-21 Drug class (es), including metabolites(s) if 
performed and or HCPCS code G0483 which represents testing 22 or more drug class(es), including 
metabolites(s) if performed, the use of these two codes cannot possibly be billed.  
We looked at the file and Medicare rules. The code billed is not payable under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for drug testing (G0483) provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for food and lodging expenses provided from August 17, 
2023, to August 19, 2023. 
 
You asked the Plan to reimburse for food and lodging expenses. You say that you have had to go take other 
tests out of state, and the Plan always reimbursed you for costs. The Plan denied your request. The Plan says 
food is not a reimbursable benefit. The Plan also says that this type of lodging expense is not covered by your 
transplant travel and lodging benefit. 
 
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. 
 
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 food and lodging expenses have been 
met. Specifically, the records do not show any receipts for lodging. Without those, we are unable to verify the 
lodging. Also, the record shows that food in not a reimbursable expense under this benefit. Therefore, we 
decided that the Plan does not have to reimburse for food and lodging expenses provided from August 17, 
2023, to August 19, 2023.