Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
November 6, 2021, to November 13, 2021. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you object to paying 
for $200 of the copay because you did not need to stay that extra day. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $285 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $1400 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient Hospital 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 reduce the copayment for 
the inpatient hospital stay provided from November 6, 2021, to November 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 1, 2022. 
 
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 procedure code 81479 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the records show that the 
specimen was not collected on the billed date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you saw the enrollee at a facility and the facility 
should have obtained the prior authorization. The Plan denied your request. The Plan says no prior 
authorization was 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory panel provided to the enrollee on March 11, 
2022. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says a panel constitutes a single procedural service, so one Healthcare Common 
Procedure Coding System (HCPCS) code must be submitted for the panel. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for a laboratory panel provided to 
the enrollee on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay 50% of the allowed amount for the ophthalmic imaging. We decided that 
the Plan does not have to fully pay for the ophthalmic imaging.  
  You asked the Plan to pay for the diagnostic imaging. You say that you should not have to pay for this service. 
The Plan says that this service was rendered by an out-of-network provider, and you were notified of the 
service potentially not being covered. 
 
We decided that the Plan has to pay 50% of the allowed amount for the ophthalmic imaging.  
 
The Plan says you can be reimbursed $20 for one non-Medicare covered retinal imaging rendered by a non-
participating provider. The ophthalmic imaging is considered a Medicare covered diagnostic service. Your 
contract clearly says that you only pay 50% coinsurance per day, per provider, for diagnostic procedures and 
tests. Therefore, we decided that the Plan has to pay 50% of the allowed amount for the ophthalmic imaging.  
 
We also decided that the Plan does not have to fully pay for the ophthalmic imaging. 
 
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 pay 50% 
coinsurance for the diagnostic imaging. Therefore, we decided that the Plan does not have to fully pay for the 
ophthalmic imaging. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(CPT code D6010) and implant supported crown - porcelain fused to high noble alloys (D6066). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit under the plan. 
 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of implant body: endosteal implant (CPT code D6010) and implant supported crown - porcelain 
fused to high noble alloys (D6066).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PriMatrix aand AmnioExcel skin substitutes. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a below knee 
amputation (BKA) and open leg wound with exposed at the BKA site without signs of infection or necrosis. 
The wound is treated with basic wound care and a wound vac. There is no documentation suggesting the 
requested skin substitute would be more appropriate or more effective for the enrollee than other skin 
substitutes covered by the Plan. Therefore, without sufficient support made for this request, the PriMatrix and 
AmnioExcel skin substitute will be considered not medically necessary at this time. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PriMatrix aand AmnioExcel skin substitutes.  
Local Coverage Determination (LCD) L33394 referenced by the Plan does not provide coverage criteria for the 
services at issue and was not used in the MAXIMUS determination.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gastrointestinal pathogen (GIP) panel (87506) provided on 
April 16, 2022. 
 You asked the Plan to pay for the GIP panel. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says testing for clostridium difficile 
was not performed as part of this panel; therefore, the panel is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for the GIP panel. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee reported with a diagnosis of diarrhea, unspecified. The enrollee had 3 or more 
liquid stools within the previous 24 hours. The enrollee's problem list includes gastroesophageal reflux disease 
(GERD), irritable bowel syndrome (IBS), and non-intractable cyclical vomiting with nausea. The 
documentation is insufficient to demonstrate that this panel was reasonable and medically necessary in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the GIP panel have not been met. Therefore, we decided that the Plan does not 
have to pay for a gastrointestinal pathogen (GIP) panel (87506) provided on April 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code S9328 billed for date of service March 26, 2022. 
 
You asked the Plan to pay for code S9328. You say that this code was authorized. The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of code S9328 have not been met. Therefore, we decided that the Plan does not have to pay 
for code S9328 billed for date of service March 26, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray of the abdomen (74018) provided on April 12, 2022. 
 
You asked the Plan to pay for the x-ray of the abdomen. You say that the enrollee had multiple exams done on 
this date of service. The Plan denied your request. The Plan says that another bill was paid and is an exact 
duplicate of this claim. 
 
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 74018 is radiologic examination, abdomen; 1 view. 
 
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 x-ray of the abdomen. Our reviewer says that the 
additional x-ray of the abdomen is supported in the medical records. Our reviewer found the records show two 
separate exams were performed, of 1 view of the abdomen, done on April 12, 2022. Our reviewer also found 
that these films were done for enteric tube placement, hence the necessity for the second exam. 
 
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 x-ray of the abdomen have been met. Therefore, we decided that the Plan 
has to pay for the x-ray of the abdomen (74018) provided on April 12, 2022.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an electroencephalogram (EEG) provided to the enrollee on September 
20, 2021. 
 
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 that Current Procedural Terminology (CPT) code 95822 26 (1 Unit) remains not supported, as 
there is a more appropriate code to use 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 CPT code. In this case, the CPT Code Manual definition of 
code 95822 is "Electroencephalogram (EEG); recording in coma or sleep only." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that coding is supported with the use of 
the procedure code that documents the EEG that was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
an electroencephalogram (EEG) provided to the enrollee on September 20, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Botox (botulinum toxin A). 
 
You asked the Plan to pre-approve Botox. You say that Botox was suggested to enlarge the opening in your 
stomach so food can be digested quicker, and it has improved your condition beyond expectations. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that you do 
not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found Botox is not Food 
& Drug Administration (FDA) approved for your condition. The Medicare-approved drug compendia do not 
contain a supportive citation for use of Botox for your clinical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the use of Botox (botulinum toxin A).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on January 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that you must monitor the usage of the enrollee's 
monthly supply. The Plan denied your request. The Plan says the documentation does not support the billed 
services. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. There are no recent medical records to show that the enrollee performs blood glucose testing at 
least four times per day, uses insulin with at least three daily injections, requires frequent self-adjustment of 
insulin dosage based on the blood glucose testing results. The public health emergency (PHE) waiver that was 
referenced in the appeal is not applicable as there are no records to show that the device was ordered for an 
enrollee infected with the coronavirus. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible outer covering and a K3 foot. 
 
You asked the Plan to pre-approve a flexible outer covering and a K3 foot. 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 a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 a flexible outer covering and a K3 foot. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is 
currently ambulating at K2 level and there is insufficient clinical documentation provided regarding the 
enrollees potential function for mobility with a prosthesis. There is limited physical examination 
documentation regarding the enrollees strength and range of motion. There is no documentation provided by a 
physician or health care provider other than a prosthetist and no indication that the enrollee is undergoing a 
rehabilitation program, including physical therapy. There is insufficient documentation indicating that the 
enrollee requires a covering system in order to protect his prosthesis. Therefore, the flex-walk foot and flexible 
protective outer surface covering system are not medically 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 flexible outer covering and a K3 foot have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a flexible outer covering and a K3 foot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) (L1971-RT-KX) provided on 
April 20, 2022. 
 
You asked the Plan to pay for the AFO (L1971-RT-KX). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. The file shows that code L1971 denied because the diagnosis code 
associated to it is mismatched to the procedure modifier on the claim line. The claim has diagnosis code 
M25.572 entered, which is defined as pain in left ankle and joints of left foot. The file shows the provider billed code L1971 with modifier RT, indicating right side; however, the diagnosis billed is for the left side. Therefore, 
we decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) (L1971-RT-KX) provided on 
April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on April 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were billed appropriately. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on April 1, 2021.