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

 
We decided that the Plan does not have to pay for a colorectal cancer screening (G0121) provided on June 22, 
2023. 
 
You asked the Plan to pay for a colorectal cancer screening. You say that this should be covered. The Plan 
denied your request. The Plan says the procedure code (G0121) indicates that you are not high risk, and 
therefore, the benefit allows for 1 screening colonoscopy every 10 years, but not within 48 months of a 
screening sigmoidoscopy. You had this service performed on April 21, 2022, in which the service was covered 
under the plan, exhausting the benefit for 10 years.  
 
The Plan must follow Medicare rules. Medicare rules say that 1 screening colonoscopy is covered every 10 
years for people with average risk of colon cancer.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a colorectal cancer screening have not been met. Therefore, we decided that the Plan does not have 
to pay for a colorectal cancer screening (G0121) provided on June 22, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the lumbar spine. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has chronic 
low back pain which has been increasing. Physical therapy was completed a year ago. Due to completion of 
physical therapy a year ago and increasing symptoms, an MRI of the lumbar spine is reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.  
 
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 an intraoral x-ray (D0230) provided on July 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 28, 2023. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray (D0230) provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services
provided on February 9, 2023.

You asked the Plan to pay for OIVIT services. You say that this should be paid for. The Plan denied your
request. The Plan says that OIVIT regimen is a non-covered service. Maximus overturned the Plan's denial.
The Plan requested a reopening and stated that this is not a covered service. The Plan is correct in this case.

The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning provided on August 14, 2023. 
 
You asked the Plan to pay for advance care planning. You say that the enrollee was in a nursing home setting at 
the time services were rendered. 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 advance care planning 
provided on August 14, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided on July 12, 
2023. 
 
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically 
necessary and ask that the Plan reconsiders the payment. 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 skilled nursing facility services provided on July 12, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gym membership (S9970) received on January 1, 2022. 
 
You asked the Plan to pay for a gym membership. You say that you were not aware that your reimbursement 
request had to be submitted by a certain date. The Plan denied your request. The Plan says your reimbursement 
form for your 2022 Wellness Allowance benefit was received on August 14, 2023, which is after the March 
31st deadline. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only reimbursement requests must be received by the Plan no later than March 31st of the following year.. 
 
The Plans rules for coverage of gym benefits have not been met because your reimbursement form for your 
2022 Wellness Allowance benefit was received on August 14, 2023, which is after the March 31st deadline.. 
Therefore, we decided that the Plan does not have to pay for a gym membership (S9970) received on January 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telemedicine visit provided on February
3, 2023.

You asked the Plan to waive the copayment for the telemedicine visit. You say that this was not an in person
visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned
the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case.

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 $40
copayment for each covered telehealth visit or consultation in an outpatient location with a specialist.

You have been asked to pay a $40 copayment for the telemedicine visit. This item/service falls within the
covered telehealth visit or consultation in an outpatient location with a specialist 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 telemedicine visit provided on February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87652) provided on October 17, 2022. 
 
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 87652 is Infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, quantification. 
 
We find that CPT code 87652 is not supported in the medical record. Specifically, the records do not include 
quantitative results 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 
(87652) provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012), neuromuscular 
reeducation (97112) and the message therapy (97124) provided by a chiropractor on July 21, 2023. 
 
You asked the Plan to pay for the mechanical traction therapy (97012), neuromuscular reeducation (97112) and 
the message therapy (97124). You say that you need these services for your condition which has been 
beneficial for you. You say that you cannot afford these services if they are not covered by the Plan. The Plan 
denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the mechanical traction therapy (97012), neuromuscular reeducation (97112) 
and the message therapy (97124) provided by a chiropractor on July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Guardian 4 transmitter. 
 
You asked the Plan to pre-approve the Guardian 4 transmitter. You say that you do not agree with the denial of 
the requested item. This item will be beneficial to the enrollee. The Plan denied your request. The Plan says 
only the preferred brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the continuous glucose monitor. Therefore, we decided that the Plan does not have to pre-approve the 
Guardian 4 transmitter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on June 15, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were performed by a denturist. 
 
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, fees for dentures provided by someone 
other than a dentist are a benefit exclusion. The records provided show that the dentures in dispute were 
provided by a denturist and not a dentist. Therefore, we decided that the Plan does not have to pay for a 
complete maxillary denture (D5110) provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when all requirements are met. 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 a sacroiliac joint injection a sacroiliac joint injection. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD 
requires 3 positive diagnostic SI joint maneuvers. Only one maneuver is documented. Therefore, the request is 
deemed not medically reasonable and necessary. 
 
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 sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection (27096).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0483 and 80307 for date of service May 23, 2023. 
 
You asked the Plan to pay for codes G0483 and 80307. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 G0483 is rug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed.  
 
The CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug classes, any 
number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, 
ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with 
or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, 
TOF) includes sample validation when performed, per date of service. 
 
We find that CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the 
documentation submitted do not include the confirmatory lab results to support that drug tests, definitive 22 or 
more drug classes was performed; therefore, code G0483 is not supported. The documentation submitted does 
not include laboratory results for the billed test; therefore, code 80307 is not supported. Based on this 
information, we decided that Medicare rules for coverage of codes G0483 and 80307 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes G0483 and 80307 for date of service May 
23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services and is 
now ready for LTACH admission. The Plan denied your request. The Plan says you do not meet the 
requirements for an LTACH admission. 
 
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 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on March 27, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for outpatient surgery services with an out-of-network provider. You say that you 
were unaware that the provider was out-of-network. The Plan denied your request. The Plan says services from 
non-participating providers are not covered under your plan unless they are authorized before the services are 
provided. 
 
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 outpatient surgery services provided on March 27, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee requires LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for an LTACH admission. 
 
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 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 appears to be more stable with the current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current treatment 
facility until more stable and appropriate for transfer to a lower level of care. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantages. Completion of treatment at the 
current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Acetaminophen, Atorvastatin, Brimonidine Solution, 
Dorzolamide Timolol, Famotidine, Senna, Insulin Lispro, Hydromorphone, Magnesium Hydroxide, 
Mirabegron, and Pantoprazole provided from July 31, 2023, to August 1, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was administered by hospital staff in 
conjunction with you hip replacement surgery. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for Acetaminophen, Atorvastatin, 
Brimonidine Solution, Dorzolamide Timolol, Famotidine, Senna, Insulin Lispro, Hydromorphone, Magnesium 
Hydroxide, Mirabegron, and Pantoprazole provided from July 31, 2023, to August 1, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.