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

 
We decided that the Plan does not have to pay for procedure code 34713 billed for date of service April 22, 
2022.  You asked the Plan to pay for procedure code 34713. You say that CPT code 34713 cannot be billed with 
modifier 50 so it was billed twice with modifier RT and LT. You say that the operative note and guidelines 
should be reviewed, and the claim considered for proper reimbursement. 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 procedure code 34713 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 34713 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 34713 billed for date of service April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2021, billed with 
codes 81206, 81301, 81311 
. 
 
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 correct coding requires that when a panel code is ordered, it should be billed, rather 
than the individual gene codes. 
 
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 the genetic testing provided on 
March 28, 2021, billed with codes 81206, 81301, 81311 
.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 30, 2021, billed with 
codes 81407-90XS (1 Unit), 81408-90XS (2 Units), 81201-90XS (1 Unit), 81317-90XS (1 Unit), 81295-90XS 
(1 Unit), 81298-90XS (1 Unit), 81479-90XS (1 Unit), 81432-90XS (1 Unit), 81403-90XS (1 Unit), 81404-
90XS (2 Units), 81405-90XS (2 Units). 
 
You asked the Plan to pay for the genetic testing billed. You say that this claim should be reprocessed. The 
Plan denied your request. The Plan says if a lab assays two or more genes in a patient in parallel, then those 
two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 
one 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 the genetic testing provided on 
April 30, 2021, billed with codes 81407-90XS (1 Unit), 81408-90XS (2 Units), 81201-90XS (1 Unit), 81317-
90XS (1 Unit), 81295-90XS (1 Unit), 81298-90XS (1 Unit), 81479-90XS (1 Unit), 81432-90XS (1 Unit), 
81403-90XS (1 Unit), 81404-90XS (2 Units), 81405-90XS (2 Units).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
17, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had a medical 
emergency and did not have a choice in the ambulance provider. You say that this should be fully covered. 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 $300 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $300 copayment for the ambulance services. Please note, the copayment is the 
same whether the ambulance provider is in-network or out-of-network. The ambulance services fall within the Ambulance 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 ambulance 
services provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids you purchased from an out-of-network 
provider on March 31, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you went to this provider because you saw them 
advertised on television.  You said that this provider was less expensive than the Plan providers and you 
wanted to save money. The Plan denied your request. The Plan says hearing aids purchase from non-plan 
providers are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor.  You did not use the Plan's hearing aid vendor. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aids you purchased from an out-of-
network provider on March 31, 2022.
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 you do not have the support to be safely discharged 
home and still require extensive assistance from nursing and therapy staff. You want to regain your 
independence and require intensive therapy in order to do so. The Plan denied your request. The Plan says the 
criteria for admission to an IRF are not met in this case. You can safely receive the services you need in a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 complexity of your nursing, medical and rehabilitation needs does not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, in an 
intensive rehabilitation therapy program. You do continue to have a need for skilled therapy with ongoing 
safety concerns and a potential for functional improvement; however, the documentation does not support that 
you meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
require skilled rehabilitation in an IRF, with a minimum of 15 hours of rehabilitation therapy services per 
week, under the supervision of a physician with at least three weekly visits to regain or maintain your 
functional status. You can receive further services in a lower level of 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency wheelchair van transportation (A0130). 
 
You asked the Plan to pre-approve wheelchair van transportation. You say that you need these services to get to 
your medical appointments. The Plan denied your request. The Plan says neither Medicare nor the Plan covers 
transportation services provided in a vehicle other than an ambulance. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency wheelchair van transportation (A0130).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Zoll life vest provided on August 12, 
2021. 
 
You asked the Plan to waive the coinsurance for the life vest. You say that you were told you would not be 
responsible for any payment. 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $615.60, which is 20% of the allowed amount for the life vest ($3,078.02 x 20% = 
$615.60). The life vest falls within the Durable Medical Equipment (DME) 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. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the Zoll life vest provided on August 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy (PT) visits to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT visits. The Plan denied your request. The Plan says there are in-
network physical therapy providers available for you. 
 
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 
12 physical therapy (PT) visits to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942-LT billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for code 76942-LT. You say that the medical records support payment of this code. 
The Plan denied your request. The Plan says code 76942-LT is not supported in the medical record. 
 
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 76942-LT is Ultrasonic guidance for needle placement 
(e.g., biopsy, aspiration, injection and localization device), imaging supervision and interpretation. 
 
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 code 76942-LT. Our reviewer says that code 76942-LT is not 
supported in the medical record. Our reviewer found the operative report describes venous chemical 
ablation. For CPT 76942 (Per NCCI Policy) "needle placement is required for procedures such as breast biopsies, needle aspirations, injections, or placing localizing device".  In this case, this procedure code cannot 
be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 76942-LT have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76942-LT billed for date of service March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to provide coverage for the original imaging request.
You and your physician asked the Plan to provide coverage for an MRI of the bilateral breast, a PET scan, and a CT scan. You say that at the time of the appeal, the requested imaging was medically necessary. The Plan denied your request. The Plan says after these services were requested, a discussion with your physician confirmed the computed tomography services approved by the plan would be appropriate. Therefore, the original request would have been dismissed as those services were no longer requested.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. During the course of the appeal and consultation with your physician, the request for an MRI of the bilateral breast, PET scan and CT scan was no longer necessary. The Plan and your physician agreed on an alternate type of imaging with computed tomography and the original request to include the MRI and PET imaging services no longer required review. Therefore, we have decided that the Plan is not required to provide coverage for MRI of the bilateral breast, PET scan and CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor for the enrollee.
You asked the Plan to provide coverage for a continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says all of the required coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not follow the Medicare guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The Medical records clearly show the enrollee is not taking 3 shots per day nor does the enrollee meet all the criteria required for coverage. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide coverage for a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided from October 20, 2021, to October 26, 2021, coded as D0140 and D0270.
You asked the Plan to pay for the dental services coded as D0140 and D0270. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plans denial for a lack of claim information in the file showing these services were previously covered. The Plan requested a reopen and provided information to show these benefits were exhausted on September 14, 2021.
The Plan is correct in this case. 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, certain limitations apply. The record shows your benefit for the codes in question was exhausted on September 14, 2021ervice. Therefore, we decided that the Plan does not have to pay for dental services provided from October 20, 2021, to October 26, 2021, coded as D0140 and D0270.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for a diagnostic colonoscopy with polyp removal provided on October 29, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this was a diagnostic colonoscopy with polyp removal which requires cost share. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required medical records.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay cost share for any colonoscopy that results is polyp removal. The medical records state this was a diagnostic colonoscopy ordered for a history or high-risk colon cancer surveillance with a personal history of colonic polyps. The records show a 10 mm polyp was found in the descending colon, removed and sent for biopsy. 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 cost share charged for a diagnostic colonoscopy with polyp removal provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support 
the need for the surgery to be provided in an inpatient setting. The Plan denied your request. The Plan says the 
planned procedure is no on the Medicare Inpatient Only List. The Plan says that there is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan says that 
if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level care 
can be performed on concurrent review with updated clinical information. 
 
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 pre-approve an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are 
met in this case. Our physician reviewer found the total knee replacement surgery can be safely performed on 
an observational 48-hour stay. Our physician reviewer found that there is nothing documented to show it is 
medically necessary to have the surgery performed at the inpatient level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete maxillary denture (D5730) provided by a 
participating provider on April 20, 2022. 
 
You asked the Plan to pay for a reline complete maxillary denture. You say that you were told you would only 
have to pay for the office fee. The Plan denied your request. The Plan says the rendered dental service 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 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. Therefore, we decided that the Plan does not have to pay for a reline 
complete maxillary denture (D5730) provided by a participating provider on April 20, 2022.