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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 83970, 84100) 
provided on July 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The documentation submitted showed that the laboratory tests reported were related to treatment of 
ESRD since end-stage renal disease was indicated as a reason for the laboratory tests, and a separate 
professional visit unrelated to ESRD was not indicated in the medical record. Therefore, the laboratory tests are 
included in the dialysis services. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (CPT code(s): 82310, 83970, 84100) provided on July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that the enrollee needs approximately 25 
more days of care and treatments that can only be given in a hospital setting. 
 
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. The patient 
appears to be still somewhat unstable and requires short-term additional acute care services including 
additional wound care that can safely be administered at the current facility until more stable and appropriate 
for a lower level of care. The patient does not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that the patient requires that are not already available 
and covered at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services.  
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided 
December 15, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date 
of service. Please reconsider for processing. The Plan denied your request. The Plan says the primary insurance 
Explanation of Benefits is needed before the claim can be processed. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the claim must be 
submitted to the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for the 
diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the radiologic examination, chest (71045) provided December 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the general anesthesia services provided on August 20, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the provider should be paid for these 
services. The Plan denied your request. The Plan says that this providers taxonomy code is 390200000X - 
Student in an Organized Health Care Education/Training 
Program. This means that the provider was not eligible to bill for anesthesia services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial is based on the National Provider Identification (NPI) number 
of the physician at issue indicating a taxonomy of Student. The Plan argues that this means that the enrollee 
was not able to provide and be paid for anesthesia services. However, the NPI website includes a disclaimer 
indicating that the issuance of an NPI does not validate licensing or credentialing. In addition, the NPI 
taxonomy is self-reported by the physician, and it would not be considered a primary source to prove whether 
the physician was a student at the time the services were rendered. Maximus verified with the Commonwealth 
of Massachusetts medical license database that the physician was a licensed anesthesiologist on this date of 
service. As such, the denial of payment based on eligibility to be paid for anesthesia services is not supported. 
Therefore, we decided that the Plan has to pay for the general anesthesia services provided on August 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical techniques requiring use of robotic surgical 
system (CPT code S2900) provided on August 6, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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 CPT code. 
 
CPT code S2900 has status code I which is not valid for Medicare purposes. Medicare uses another code for 
reporting of and payment for these services. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical techniques requiring use of robotic surgical system (CPT code S2900) provided on August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81238, 81220, 81225, 
81230, 81227, 81355, 81241, 81291, and 81240) provided on July 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. As Comprehensive 
Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently 
satisfactorily described by any existing CPT code; to report a CGP, service providers should use 1-unit only 
of CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved 
DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. 
 
Furthermore, CPT code 81226, 81306, 81328, 81335, 81231, 81232, 81283, remain not supported. The place of 
service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 
22, 2021, and received by the lab on August 04, 2021. Of note, the patient resides in Florida (FL) and the 
billing laboratory is located in Texas (TX); therefore, the billed code cannot be verified. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code(s): 81238, 81220, 81225, 81230, 
81227, 81355, 81241, 81291, and 81240) provided on July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 7, 2021, to February 10, 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 the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 163 (MAJOR CHEST PROCEDURES WITH 
MCC). 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 services. Our reviewer says that the 
services at issue in this cases were not supported by the medical records. Our physician reviewer found the 
review has determined that the records did not support secondary diagnosis code - J96.01 - in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from February 7, 2021, to February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on November 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that the service was rendered to the enrollee out of 
medical necessity, and you would like the claim processed for payment. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent and there were 
in-network providers available that provide the same quality of service. 
 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 had network providers 
available who could have provided 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 the surgery services provided on November 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from February 14, 
2021, through March 12, 2021. 
 
You asked the Plan to pay for the home health care services. You say that the claim should be paid. 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 CPT code. 
 
 The claim was submitted with an incomplete or invalid procedure code. Per CMS.gov Chapter 10 - Home 
Health Agency Billing Section 40.2, a claim cannot be billed without a Q code. Based on this information, we 
decided that Medicare rules for coverage of the home health care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health care services provided from February 14, 2021, 
through March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81235, and 
81321) provided on February 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The denial remains 
upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81235, and 81321) provided on February 16, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82728, 83540, and 
83550) provided on August 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 CPT code. 
 
The provider did not bill as required by Medicare coding regulations. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (CPT code(s): 82728, 83540, and 83550) provided on 
August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foam dressing (CPT code A6212) provided on January 
28, 2022. 
 
You asked the Plan to pay for the foam dressing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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 CPT code. 
 
 
CPT code A6212-Al, which has a status indicator of'P' on the CMS Physician Relative Value File, and is 
always bundled into payment for other services not specified and no separate payment is made per Medicare.  
 Based on this information, we decided that Medicare rules for coverage of the foam dressing have not been 
met. Therefore, we decided that the Plan does not have to pay for the foam dressing (CPT code A6212) 
provided on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiographic image of the chest (x-ray) (71045), provided 
on June 3, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the services are medically necessary. The Plan 
denied your request. The Plan says with the information we have, we cannot determine how the member came 
to the servicing provider, or whether the services are medically necessary. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the radiographic image of the chest (x-
ray) (71045), provided on June 3, 2021. have been met. no medical records were submitted in order to 
determine medical necessity. Therefore, we decided that the Plan does not have to pay for the radiographic 
image of the chest (x-ray) (71045), provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on February 19, 2020, and 
August 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that you caught COVID-19, moved twice, and 
understood you had 18 months to submit the claim. You also say that you would like these services to be 
reconsidered for coverage. The Plan denied your request. The Plan says this request was received after the 365-
day timely filing limit for dental reimbursements. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until October 29, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the dental services provided on February 19, 2020, and August 
20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
December 9, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would not have gone to 
this provider if you had known this service would not be fully covered by the Plan. You also say that you feel 
you were overcharged. The Plan denied your request. The Plan says this service is not a covered expense under 
your dental plan. 
 
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 
complete series of intraoral x-rays (D0210) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 6 posterior resin-based composites of one surface (D2391 
x6) and 10 posterior resin-based composites of three surfaces (D2393 x10) provided on January 12, 2022. 
 
You asked the Plan to pay for the posterior resin-based composites. You say that your benefits could not have 
been satisfied prior to this claim, because this is the only dental claim you have filed. You also say that your 
claim frequency could not have exceeded the limit because this is the very first one. The Plan denied your 
request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been 
exceeded. 
 
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, restorations are limited to 2 procedure 
codes per calendar year. The record shows that you received two anterior resin-based composites (D2330 and 
D2332) on January 12, 2022 and your restorations benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the 6 posterior resin-based composites of one surface (D2391 x6) and 10 
posterior resin-based composites of three surfaces (D2393 x10) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three two dimensional (2D) oral/facial photographic 
images (D0350 x3) provided on November 22, 2021. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you told the dentists not to 
give you another x-ray because you had one taken recently. You also say that it is not fair that you are being 
charged for the x-rays. The Plan denied your request. The Plan says this service is not a covered expense under 
your dental plan. 
 
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 three 
two dimensional (2D) oral/facial photographic images (D0350 x3) provided on November 22, 2021.