Persius/hicric huggingface dataset:
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 you are appealing because the enrollee prefers not to 
fingerstick. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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 the CGM have been met. Specifically, 
documentation shows that the Plan made multiple attempts to obtain medical records from the enrollees 
treating physician. Without medical records we cannot determine if the Medicare guidelines for the requested 
CGM were met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided on 
January 17, 2023. 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you have paid for the 
equipment for long enough and it should by paid by now. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the oxygen equipment. This item/service falls within the 
durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The record shows this claim was approved and you are 
responsible for the cost share amount. The total you owe is $27 ($135 allowed amount x 20% coinsurance = 
$27). Therefore, we decided that the Plan does not have to waive the coinsurance for the oxygen equipment 
provided on January 17, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 3, 2022.
You asked the Plan to pay for procedure code 76641. You say that the records support the procedure. 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 that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99213) injection of drug or substance 
under skin or into muscle (96372) dexamethasone sodium phosphate (J1100) injection, triamcinolone 
acetonide, not otherwise specified, 10 mg (J3301) provided November 30, 2022. 
 You asked the Plan to pay for the office visit. You say that please review the attached supporting 
documentation and kindly reprocess for payment. The Plan denied your request. The Plan says the diagnosis 
code on this claim is not covered. 
 
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 diagnosis code used for this claim is K04.7: periapical abscess without sinus. 
 
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 office visit. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found these 
codes are not eligible for reimbursement consideration. The billing records provided indicate the diagnosis 
code submitted to the health plan associated with the procedure codes performed on November 30, 2022, is 
K04.7: periapical abscess without sinus, which is not covered under the Plan, therefore CPT codes 99213, 
96372, J1100 and J3301 does not meet criteria for reimbursement consideration. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient office visit (99213) injection of drug or substance under skin or into muscle (96372) 
dexamethasone sodium phosphate (J1100) injection, triamcinolone acetonide, not otherwise specified, 10 mg 
(J3301) provided November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on January 16, 
2023. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was part of your annual 
diabetic eye exam. 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 $40 
copayment for vision services. 
 
You have been asked to pay a $40 copayment for the eye exam. This item/service falls within the vision 
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. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam provided on 
January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic footwear. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for acute inpatient hospital care to be provided 
after lumbar laminectomy surgery. 
 
You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient care is 
medically necessary. The Plan denied your request. The Plan says inpatient care after a lumbar laminectomy is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 provide coverage for acute inpatient hospital care. 
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the record did not show that the admitting physician reasonably 
expects that your necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for acute inpatient hospital care to be provided after lumbar 
laminectomy surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, diabetic footwear. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, diabetic footwear.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services provided on January 
06, 2023. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that you have never had to pay 
for the podiatrist before. 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 $15 
copayment for podiatry services. 
 
You have been asked to pay a $15 copayment for the podiatry services. This item/service falls within the 
podiatry 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. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry services 
provided on January 06, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 13, 2022 to 
February 10, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 12, 2022. The NOA was not received by the Plan until October 26, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on January 13, 2022 to February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on November 
08, 2022. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you were not made aware of 
this copayment and want it waived. 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 $195 
copayment for outpatient surgery. 
 
You have been asked to pay a $195 copayment for the cataract surgery. This item/service falls within the 
outpatient surgery 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 cataract surgery 
provided on November 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from March 29, 2021, to March 31, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met because an appropriate "Present on admission" (POA) code was not submitted on the claim. Maximus overturned the Plans denial because a claim was not submitted with the file. The Plan requested a reopen and provided a copy of the claim at issue.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim was not submitted with a valid POA code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from March 29, 2021, to March 31, 2021.
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 the member is medically stable and 
ready for the next level of care. The Plan denied your request. The Plan says the member is receiving 
appropriate in-patient acute care and is currently unstable for transfer to 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 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 health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) with procedure 
codes S8037, 74183, 74182, 0724T. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary because you 
have had issues for over 6 months with your stomach and your provider can't figure out why. The Plan denied 
your request. The Plan says there is no indication that you have had treatment for conditions that are more 
likely to be causing the symptoms. 
 
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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have a history of pyloric stenosis and 
repair since you were an infant. You have chronic abdominal pain and had a negative colonoscopy. You have 
not had an endoscopy. On April 28, 2022, you had a normal computerized tomography (CT) scan. The are no 
gastroenterologists consults for esophagogastroduodenoscopy (EGD) therefore the medical necessity of the 
requested MRI of the abdomen has not been established. 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) with procedure codes S8037, 74183, 74182, 0724T.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair (K0007). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the enrollee is not able to use their power 
wheelchair on rainy days or when driven somewhere because there is no way to get the power wheelchair into 
the vehicle. The enrollee would like a manual chair for this situation. The Plan denied your request. The Plan 
says an additional chair is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power wheelchair. The power wheelchair serves the same purpose as a 
manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty 
wheelchair (K0007).
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 the LTACH services. You say that an LTACH is the appropriate level of 
care for the enrollee, the enrollee is medically stable to be transferred to the LTACH, and you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for admission to 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 that there is no documentation provided indicating medical necessity for admission to 
an LTACH. 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan for measuring 
calcium and other minerals in the bones. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are necessary due to the enrollee's 
age and history of multiple medical issues. The Plan denied your request. The Plan says the records don't show 
any disorders that affect the enrollee's bone mineral density. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is post-menopausal and received 
a dual x-ray absorptiometry (DEXA) scan on January 31, 2019, which showed osteopenia. Due to the enrollee's 
age and history of osteopenia, they would qualify for a DEXA scan. There is no indication for a CT scan for 
bone density. 
 
 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan for measuring calcium and other minerals in the bones.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services on 
November 10, 2022, to November 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient mental health services. You say that you were 
involuntarily committed as a patient and did not consent to treatment. 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 $374 
copayment per day, days 1-5: $0 per day, days 6-90, after your $1,000 plan deductible, for inpatient services. 
Covered services include mental health care services that require a hospital stay. 5 x $374 = $1,870. Therefore, 
results in the total cost sharing amount of $1,870. You have been asked to pay a $374 copayment per day for inpatient mental health services. This item/service 
falls within the inpatient mental health care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for inpatient mental health services on November 10, 2022, to November 23, 2022.