Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided 
from January 8, 2020 to March 18, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered 
benefit. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9328 provided from January 8, 2020 to March 
18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the impacted tooth removal (D7241), consultation (D9310) 
and therapeutic parenteral drugs (D9612) provided on March 17, 2020. 
 
You asked the Plan to pay for the impacted tooth removal (D7241), consultation (D9310) and therapeutic 
parenteral drugs (D9612). You say that you do not have any medical training and are not qualified to make 
decisions on which sedation to use. You say that you expected the surgeon to use their knowledge and 
experience to do so. The Plan denied your request. The Plan says the 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 Plan?s 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 the 
impacted tooth removal (D7241), consultation (D9310) and therapeutic parenteral drugs (D9612) provided on 
March 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a refill of an infusion pump (62369) on 
March 18, 2020. 
 
You asked the Plan to waive the copayment for a refill of an infusion pump. You say that you're being charged 
a larger copayment for this service than you've had to pay before. The Plan denied your request. The Plan says 
the correct copayment was applied. 
 
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 $350 
copayment for each covered surgery or surgical procedure performed as an outpatient at a hospital.  
 
You have been asked to pay $252.64 for a refill of an infusion pump. A refill of an infusion pump, when 
performed as an outpatient at a hospital, falls within the Outpatient hospital services benefit category. This 
means that you have been asked to pay less than the full 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 a refill of an infusion pump (62369) on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the 
out of network (OON) provider on February 5, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care (99309) rendered by the out of network (OON) provider on 
February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 6,
2020.
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 the denied codes remain 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 the denied codes is:
CPT 81057:
Carbamepazine; free
CPT 80159:
Clozapine
CPT 80162:
Digoxin; total
CPT 80173:
Haloperidol
CPT 80177:
Levetiracetam
CPT 80201:
Topiramate
HCPCS G0483:
Drug 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
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician
order for these services, and the services were done by urine sampling rather than blood sampling. 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 drug testing services provided to the enrollee on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on October 22, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were provided in a facility. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. 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 physician services provided on October 22, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on January 28, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a precision denture attachment.
You asked the Plan to pre-approve the attachment. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Denture attachments are not covered. Therefore, we decided that the Plan does not have to pre-approve a precision denture attachment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on April 15, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 has network providers 
available who can provide 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 lab work provided on April 15, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on 
April 6, 2020. 
 
You asked the Plan to pay for these services. You say that the procedure was done because a certain tissue of 
your body was suspected of being cancerous. The Plan denied your request. The Plan says that this is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the 
incisional biopsy of oral tissue (D7286) provided on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 18, 
2019. 
 
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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes 
 
We find that the denied CPT codes are not supported in the medical record. Specifically, the place of service on 
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects 
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11) 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 drug testing services provided to the 
enrollee on April 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyewear rendered on March 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee has exhausted the benefit limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan reimburses up to $75 per calendar year towards the purchase of eyeglasses or contact lenses. 
 
We looked at the file and the Plan's rules. The file shows that the Plan reimbursed the full $75 benefit for 
routine eyewear purchased on March 11, 2020. Further reimbursement is not covered by Medicare or the Plan?s 
supplemental routine eyewear benefit. Therefore, we decided that the Plan does not have to pay for the routine 
eyewear rendered on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 3, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 find that CPT codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical 
record. The material used to exam this testing is whole blood, serum, plasma, or cerebrospinal fluid. The 
documentation does not show that this material was obtained from the enrollee for the testing services at issue. 
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 the lab services provided on January 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract removal with insertion of lens 
(66982) performed on May 12, 2020. 
 
You asked the Plan to waive the copayment for a cataract removal with insertion of lens. You say that the 
service was initially scheduled for a date prior to your enrollment with the Plan and postponed due to the 
COVID-19 emergency. Your prior insurance would have had a lower copayment. You asked the Plan to match 
the prior insurance's price. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $600 
copayment per visit for outpatient surgery.  
 
You have been asked to pay a $600 copayment for a cataract removal with insertion of lens. A cataract removal 
with insertion of lens falls within the "Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers" 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 a cataract removal with insertion of lens (66982) performed on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 3, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to 
be performed the some of the tests billed do not match the specimen type for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on February 3, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing of 8-14 drug classes provided on June 11, 2019 billed with code G0481.
You asked the Plan to pay for the definitive drug testing as billed. You say that the records clearly show this testing was needed and billed correctly. The Plan denied your request. The Plan says that the documentation does not show that between 8-14 drug classes were tested, based on the classes listed in the LCD.
Please note that Maximus reviewed the applicable LCD and we find that the drug classes listed are not exhaustive and cannot be interpreted as the only billable drug classes.
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 G0481 is Drug 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; 8-14 drug class(es), including metabolite(s) if performed. We find that CPT code G0481 is supported in the medical record. Specifically, the lab report clearly shows more than 8 drug classes were tested. Drug classes for billing purposes are defined in the CPT Manual. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing as billed have been met. Therefore, we decided that the Plan has to pay for the definitive drug testing of 8-14 drug classes provided on June 11, 2019 billed with code G0481.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Group 2 power wheelchair (PWC) rental with joystick 
billed with date of service September 22, 2019. 
 
You asked the Plan to pay for the PWC rental. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says the documentation does not include proof of delivery 
which validates the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The claim was 
billed with modifier KI which indicates that this is for the second or third month's rental of the PWC; however, 
there was no evidence that the PWC was delivered prior to the billed date of service. The only documentation 
available is a delivery ticket with an order date of October 2019, which does not correspond to the billed rental 
date. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the Group 2 power wheelchair (PWC) 
rental with joystick billed with date of service September 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 17, 2019. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the order provided does not specify the testing to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a 
treating provider. 
 
The order form does not specify the drugs to be tested in the requested panel. As such, it cannot be confirmed 
that this testing was intended as provided. Therefore, we decided that the Plan does not have to pay for the drug 
testing provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 11042) provided to the enrollee on 
March 3, 2020. 
 
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 this was not coded correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that CPT code 
the services has a bundled relationship with CPT code and cannot be paid as billed. This code cannot be paid as 
a separate line item without the appropriate modifier appended. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 
11042) provided to the enrollee on March 3, 2020.