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

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 4, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E2394 billed for date of service April 10, 
2023.   

You asked the Plan to pay for procedure code E2394. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.  
 
In this case, the MUE for CPT code E2394 is 1. The MAI value for this code is 1. You billed 2 units of this 
code, exceeding the MUE. The units in excess of the MUE were not reported on a separate claim line with an 
appropriate modifier as required. Based on this information, we decided that Medicare rules for coverage of 
procedure code E2394 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code E2394 billed for date of service April 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95811) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a sleep study with an out-of-network provider. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the requested service is not urgent or 
emergent and it is available with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a sleep study (95811) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 21, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
 
 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. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient consult to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an outpatient consult. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says this provider is out-of-network, and the services 
could be performed in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient consult to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that these services are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for LTACH services.
Our Medical Director states that the available clinical documentation does not support that the enrollee in this
case required services at the LTACH that were not available at the acute care hospital where she was receiving
care. There are no required medical services identified that are available at the LTACH, that were not available
at the health care setting being offered by the health plan. Consequently, the requested LTACH services were
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. Our
Medical Director found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the retreatment of previous root canal therapy (D3348) and inhalation 
of nitrous oxide/analgesia (D9230) provided on March 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan to see what would be 
covered and you were told that you had $2,000 to spend any way needed. The Plan denied your request. The 
Plan says the frequency limitation for the retreatment of previous root canal therapy has been exceeded. The 
Plan also says that inhalation of nitrous oxide/analgesia is not a covered expense under the plan. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan says the frequency limitation for the root canal retreatment 
has been exceeded and the nitrous oxide/analgesia is not a covered benefit. However, the Plan did not submit 
documentation showing root canal retreatment was already provided on tooth #19. In addition, nitrous 
oxide/analgesia is listed as a covered benefit with covered procedures. This means that the Plans denial of the 
retreatment of previous root canal therapy (D3348) and inhalation of nitrous oxide/analgesia (D9230) is not 
supported. Therefore, we decided that the Plan has to pay for the retreatment of previous root canal therapy 
(D3348) and inhalation of nitrous oxide/analgesia (D9230) provided on March 13, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3310), a diagnostic service 
consultation (D9310), pulp vitality tests (D0460), and an intraorifice barrier (D3911), provided on August 22, 
2023. 
 
You asked the Plan to pay for D3310, D9310, D0460, and D3911. You say that you would like the Plan to pay 
for this dental work. The Plan denied your request. The Plan says the rendered dental services are not covered 
benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3310), a diagnostic service consultation (D9310), pulp vitality tests (D0460), and an 
intraorifice barrier (D3911), provided on August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an advanced knee feature (L5814, L5845,
L5848, L5850, L5925) for a prosthetic leg for the enrollee.

You asked the Plan to provide coverage for this prosthetic equipment. You say that at the time of the appeal,
this prosthetic equipment was medically necessary. The Plan denied your request.

The Plan says the Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the medical
records show the enrollee is currently using a tall front wheeling walker for ambulation. This is not consistent
with an enrollee who is stated to be a K3 ambulator.

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. Based on the medical records provided, the enrollee does not meet the
definition of a K3 ambulator. Therefore, we decided that the Plan does not have to provide coverage for an
advanced knee feature (L5814, L5845, L5848, L5850, L5925) for a prosthetic leg for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission from August 24, 2023, through August 25, 
2023. 
 
You asked the Plan to pay for the inpatient admission from August 24, 2023, through August 25, 2023. You 
say that the services were medically necessary. The Plan denied your request. The Plan says that the services 
were not medically necessary because the records show the enrollee did not have hemodynamic instability, 
hypoxemia, constrictive pericarditis, or signs of myocarditis, arrythmias, respiratory symptoms, fever, or severe 
pain requiring inpatient treatment. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the inpatient 
admission from August 24, 2023, through August 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for established patient provided on October 11, 2023. 
 
You asked the Plan to pay for established patient. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you used the requested service on June 6, 2023. 
 
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 established patient provided on October 11, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 4, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that your Plan is supposed to cover a portion of the cost 
of mental health/behavioral therapy, which states that 70% of the allowed amount should be covered. The Plan 
denied your request. The Plan says this provider is a Medicare opt out provider and not eligible to be part of the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87561) provided on April 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 87561 is Infectious agent detection by nucleic acid (DNA 
or RNA); Mycobacteria avium intracellulare, amplified probe technique.  
 
We find that CPT code 87561 is not supported in the medical record. Specifically, no results were provided for 
this test. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (87561) provided on April 
18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this is a non-covered item. 
 
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 (E0675).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for carpal tunnel surgery (76942) provided on July 20, 2023. 
 
You asked the Plan to pay for carpal tunnel surgery (76942). You say that the service was necessary and 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 carpal tunnel surgery 
(76942) provided on July 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for chemotherapy services and acute inpatient stays 
provided from January 4, 2023, to February 15, 2023. 
 
You asked the Plan to waive the cost for chemotherapy and inpatient services. You say that you should only 
owe a 20% 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 a 20% 
coinsurance for Medicare Part B drugs, and a $290 copayment for Medicare-covered surgery or other services 
provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and 
physician or surgical charges You have been asked to pay a $1,066.77 total cost for chemotherapy and inpatient services ($711.18 + $355.59 
= $1,066.77). This item/service falls within the Medicare Part B drugs and Medicare-covered surgery, or other 
services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges 
and physician or surgical charges 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 cost for 
chemotherapy services and acute inpatient stays provided from January 4, 2023, to February 15, 2023.