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

 
We decided that the Plan does not have to pay for 2 units of procedure code 27096 billed on November 5, 
2021.  You asked the Plan to pay for 2 units of procedure code 27096. The Plan denied your request. The Plan says 
CPT code 27096 has an MUE value of 1 but 2 units were billed. 
 
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 27096 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 2 units of 
procedure code 27096 have not been met. Therefore, we decided that the Plan does not have to pay for 2 units 
of procedure code 27096 billed on November 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal pulse activation therapy (EPAT) provided on 
August 13, 2021. 
 
You asked the Plan to pay for EPAT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of the requested 
services have not been met. 
 
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 EPAT. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 
the progress notes are void of detail with regard to prior treatment for the enrollee's right heel pain. The 
available progress notes only advise of prior EPAT treatments. There are multiple very conservative treatment options for plantar fasciitis/heel pain. The available medical documentation is void of the more common 
standard of care treatments for plantar fasciitis. EPAT is not proven to be more beneficial than existing, 
available, medically appropriate, alternative treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EPAT have not been met. Therefore, we decided that the Plan does not have to 
pay for EPAT provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 23, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
services were received as an emergency response to a fire at your home, but you did not consent to any 
treatment or transport. You also say that they checked your vitals, but you did not expect to get a bill for their 
services. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 23, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on January 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81275, 81276, 81206, 81301, 81404) provided 
September 20, 2021. 
 
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 claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81275, 81276, 81206, 81301, 81404) 
provided September 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation to dialysis. The Plan denied your request. The Plan says the enrollee has utilized the maximum 
number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on October 5, 2021, to January 
19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you are requesting reimbursement for these 
claims. 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 
podiatry services. We found no exception that would require the Plan to pay for the podiatry services. 
Therefore, we decided that the Plan does not have to pay for podiatry services provided on October 5, 2021, to 
January 19, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the long-term acute care 
hospital (LTACH) services you and/or your provider are requesting do not meet the requirements for approval. 
 
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 the enrollee continues to receive acute care services and these have not been denied.  
The medical record does not indicate that the enrollee requires services that he is not currently receiving but 
that would be available at the LTACH facility.  The elements of the coverage rules are not satisfied.  The 
requested service cannot be 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and records show that it is not reasonable to 
expect that the enrollee will be able to safely participate in, or fully benefit from, the intensity of services in an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees care needs can be met at a lower level of care such as in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ascending aorta graft (33859) provided on December 22, 
2021. 
 
You asked the Plan to pay for the ascending aorta graft (33859). The Plan denied your request. The Plan says 
procedure code 33533 was approved, and procedure code 33859 is not supported by the medical records 
submitted. 
 
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 33859 is ascending aorta graft, with cardiopulmonary 
bypass, includes valve suspension, when performed; for aortic disease other than dissection (eg, aneurysm). 
 
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 ascending aorta graft (33859). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not include enough information to confirm an ascending aorta graft with cardiopulmonary 
bypass for aortic disease other than dissection.  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 ascending aorta graft (33859) have not been met. Therefore, we decided that 
the Plan does not have to pay for the ascending aorta graft (33859) provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The medical records provided do not show that the enrollee 
experienced at least 50% sustained pain relief for at least three months. The records show that the enrollee 
received an epidural injection in March 2022, and at his visit in April 2022, the pain had returned. Based on 
this information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the hospital bed. You say that the enrollee has a problem with muscular 
weakness and needs the hospital bed. The Plan denied your request. The Plan says this item is not covered 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed (E0265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute rehab to 
optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says that the 
services the enrollee needs can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. The Plan denied your request. The Plan says that this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 radiation therapy. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that radiation is a standard approach to the treatment of skin cancer and is often the preferred 
approach to maximize cosmesis for facial lesion (as opposed to surgery). While NCCN guidelines do not 
advocate for the use of brachytherapy for skin cancers, it is clear that several American societies consider it an 
accepted standard of care. Thus, standard medical necessity criteria are met for the use of HDR brachytherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve radiation therapy.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TVAR) and 
related services provided from November 7, 2021, through November 11, 2021. 
 
You asked the Plan to pay for the TVAR and related services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number 
on claims for items/services provided in clinical trials/studies/registries, or under coverage with evidence 
development (CED). 
 
We looked at the file and Medicare rules. In this case, the services at issue were provided under a CED clinical 
trial. The claim at issue did not include the appropriate clinical trial number. Based on this information, we 
decided that Medicare rules for coverage of the TVAR and related services have not been met. Therefore, we 
decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TVAR) and related 
services provided from November 7, 2021, through November 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug test labs (G0480, G0481, G0482, G0483) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve drug test labs to be provided OON. You say that you want the Plan to cover 
these services. The Plan denied your request. The Plan says these services are not covered out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
drug test labs (G0480, G0481, G0482, G0483) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 2 over-the-counter (OTC) coronavirus test kits 
purchased on January 18, 2022. 
 
You asked the Plan to reimburse you for the OTC coronavirus tests. You say that you were under the 
impression that Medicare was covering coronavirus tests. The Plan denied your request. The Plan says the OTC 
coronavirus tests were not covered by Medicare until April 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that as of April 4, 2022, coverage will allow for up to 
eight over-the-counter COVID-19 tests each calendar month, at no cost to you.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTC test have not been met. Specifically, the record shows that the OTC test kits were 
purchased prior to April 4, 2022. Therefore, we decided that the Plan does not have to reimburse you for the 2 
over-the-counter (OTC) coronavirus test kits purchased on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis rendered on January 
12, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that biomarker testing is covered when specific 
criteria 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 to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had a left lung nodule. A 
core needle biopsy was noted to be non-small cell carcinoma, favoring adenocarcinoma. A core needle biopsy 
was noted to be non-small cell carcinoma, favoring adenocarcinoma. The documentation does not support that 
the Caris targeted genomic sequence analysis met the criteria for coverage and was medically reasonable and 
necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the targeted genomic sequence analysis rendered on January 12, 2022.  
 
LCD L36254 referenced by the Plan is not valid for the state of Texas where the testing was performed and 
was not used in the MAXIMUS determination.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ultrasound on March 01, 2022, to March 
03, 2022. 
 
You asked the Plan to waive the copayment for Ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
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 $50 
copayment for other Medicare-covered diagnostic procedures and tests. Covered services include, but are not 
limited to: Other outpatient diagnostic tests, which may include: Ultrasound.  
 
You have been asked to pay a $50 copayment for Ultrasound. Ultrasound falls within the Outpatient diagnostic 
tests and therapeutic services and 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. Therefore, we decided that the Plan does not have to waive the copayment 
for Ultrasound on March 01, 2022, to March 03, 2022.