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

We decided that the Plan does not have to pre-approve the destruction of skin lesions provided to the enrollee
on December 7, 2022.

You asked the Plan to pre-approve destruction of skin lesions. You say that this treatment was medically
necessary for the enrollee. 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.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for destruction of skin
lesions. The Maximus Physician Reviewer determined that the requested services were medically reasonable
and necessary in this case. The reviewer found that the term "pre-malignant" was used to describe the skin
lesions, and consequently, the enrollee had a covered indication for these services. The Plan requested a reopen
and stated the physical examination contradicts the assertion that the skin lesions were pre-malignant." The
physical examination clearly documented "no abnormal nevi" and "several benign looking SK's on back and
trunk". The Plan notes that there is no documentation of bleeding, persistent or intense itching, pain, or any of
the other criteria established in the LCD. Additionally, the lesions are described in the Assessment/Plan as
"Disorder of the skin and subcutaneous tissue, unspecified". Specifically, the diagnoses listed did not include
any malignant lesions or lesions of uncertain behavior. The medical records show the enrollee is a 77-year-old
woman who had multiple skin lesions on her left upper back, left shoulder, left upper chest, and left posterior
thigh. The Primary Care visit on December 7, 2022, documented, "several benign looking SK's on back and
trunk". The diagnosis code was L98.9, Disorder of the skin and subcutaneous tissue, unspecified. The Plan is
correct in this case. LCD L33445, Removal of Benign and Malignant Skin Lesions, states that there may be
instances in which the removal of benign seborrheic keratoses, sebaceous cysts and viral warts is medically
appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic if one or
more conditions are present and clearly documented in the medical record. The clinical medical record does not
contain clear documentation of one or more of the listed characteristics in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of destruction of skin lesions have not been met. Therefore, we decided that the
Plan does not have to pre-approve the destruction of skin lesions provided to the enrollee on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205-57 rendered on November 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 99205-57 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that this service was performed in the 
location of on campus - outpatient hospital and describes that the enrollee presented for small bowel 
obstruction and incarcerated inguinal hernia. The provider attempted to reduce, however was unable to due to 
the enrollee being uncooperative. The provider documents that the enrollee refuses any type of surgery. In this 
case, documentation does not support the modifier billed, as decision to perform procedure was not 
documented, and cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99205-57 rendered on November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the octreotide injection and the drug 
administration provided on August 22, 2023. 
 
You asked the Plan to waive the cost share for the injection and drug administration. You say that these 
services should be covered by the Plan. 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 in-network Medicare-covered Part B prescription drugs. The Plan contract also says you must pay a $295 copayment for other in-network services provided at an outpatient hospital. 
 
You have been asked to pay $2,123, which is 20% coinsurance ($10,614.98 allowed amount x 20% 
coinsurance = $2,123). This injection falls within the Medicare-covered Part B prescription drug benefit 
category.  
 
You have also been asked to pay $111.72, which is less than the standard copayment for the drug 
administration. You have been asked to pay a total of $2,234.72 ($2,123 coinsurance + $111.72 copayment = 
$2,234.72). This service falls within the outpatient surgery and other medical services provided at hospital 
outpatient facilities 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 waive the cost share for the octreotide injection 
and the drug administration provided on August 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will be in need of intensive 
rehabilitation on their left ankle to get back to being able to walk. The Plan denied your request. The Plan says 
based on Medicare guidelines, the IRF services requested do not meet the requirements for approval.  
 
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 enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports 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. Our physician reviewer also found that 
there is not a reasonable expectation that this 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
of this decision for reconsideration. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the Plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that the enrollee has been through so 
much and he is traumatized to keep sticking his fingers as well as his erratic blood glucose levels. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the CGM. 
 
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 FreeStyle Libre 3 sensor. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found coverage criteria for 
CGM require insulin use or low blood glucose sugar. The enrollee is not taking insulin despite blood glucose 
sugar in the 300's as reported on the note. Although the CGM may help the enrollee criteria are not met. If the 
enrollee is prescribed insulin, the chart should be re-reviewed. 
 
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 FreeStyle Libre 3 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the FreeStyle Libre 3 sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging service 
provided on April 16, 2022. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging service. You say that you 
should not be charged for a service that was rendered over a year ago. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for the magnetic resonance imaging service. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the magnetic resonance imaging service provided on April 16, 2022.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code Q4262. We decided that the Plan does not have to pay 
for procedure code 15276.  
 
You asked the Plan to pay for procedure codes Q4262 and 15276 billed for date of service June 23, 2023. You 
say that these services were necessary and are supported in the medical record. The Plan says that these 
services are not supported as billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We decided that the Plan has to pay for procedure code Q4262.  
 
In this case, the CPT code manual definition of code Q4262 is dual layer impax membrane, per square 
centimeter. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code Q4262 (x70). Our reviewer says that this 
service is supported in the records provided. Our reviewer found that the procedure report for the date of 
service in question does document that IMPAX Human Amniotic Tissue Allograft was performed, and 
therefore should be covered.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for procedure code Q4262.  
 
We also decided that the Plan does not have to pay for procedure code 15276. 
 
In this case, the CPT code manual definition of code 15276 is application of skin substitute graft to face, scalp, 
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 
100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for 
primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 15276. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found that the medical record does not include 
documentation to support the additional 25 sq cm reported; therefore, this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 15276. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services and supplies provided in the United 
Mexican States from November 1, 2022, to November 17, 2022. 
 
You asked the Plan to pay for medical services. You say that you were told the Plan has all of the required 
details to make a decision. The Plan denied your request. The Plan says the Plan has not received proof of 
payment for these services, so reimbursement cannot be issued. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are only covered under limited, specified circumstances. The Plan has a 
supplemental worldwide coverage benefit that goes beyond Medicares rules. For that reason, the Plans rules 
apply to this case. The Plan covers worldwide emergency and urgent care; however, you must pay for the 
services up front and submit proof of payment to the Plan for reimbursement. 
 
We looked at the file, the Plans rules, and Medicare rules. These services do not fall within Medicares 
coverage for items and services furnished outside of the United States and its territories. Additionally, your 
claim has not met the Plans rules for coverage because you have not submitted proof of payment to the Plan 
for consideration of reimbursement. Based on this information, we decided that the Plans rules for coverage of 
medical services have not been met. Therefore, we decided that the Plan does not have to pay for medical 
services and supplies provided in the United Mexican States from November 1, 2022, to November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0452) provided on August 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0452 is "Molecular pathology procedure; physician 
interpretation and report". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code G0452 is 
not supported by the records provided. Our reviewer found that the medical record does not include a physician 
interpretation and report of a molecular pathology test, above and beyond the report of laboratory results.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (G0452) provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on 
August 16, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that the services should be 
covered. 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 a home or residence visit 
for the evaluation provided on August 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
March 24, 2023, to April 08, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. 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 $365 
copayment for inpatient hospital services. 
 
You have been asked to pay a $365 copayment for the inpatient hospital services. This item/service falls within 
the inpatient hospital 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 were charged $1,825 ($365 x 5 days). You were not charged for days 6-15. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services 
provided on March 24, 2023, to April 08, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on May 11, 2023, billed with procedure 
code 99213-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
The Plan follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We asked our coding 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 the practitioner services provided. Our 
reviewer says that the documentation does support the billed code. Our physician reviewer found that the visit 
was to follow up from an emergency department visit and was not related to the services reported with 97750. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on May 11, 2023, billed with procedure code 99213-25.  
 
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.