Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a maxillary complete denture 
(D5110) provided on March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for a panoramic x-ray was exhausted on date of service November 4, 2020. The record also 
shows your benefit for a maxillary complete denture was exhausted on date of service December 16, 2020. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a maxillary 
complete denture (D5110) provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested medial branch blocks are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested medial branch blocks (64493, 64494, and 64495). 
 
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 medial branch blocks. Our reviewer 
says that the enrollee does not meet criteria for the requested medial branch blocks (64493, 64494, and 64495). 
Our physician reviewer found the enrollee has chronic low back pain with radiation into her leg. She is taking 
Gabapentin, Oxycodone and Naproxen for pain. The request is for diagnostic medial branch blocks. Facet joint 
interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic 
pain in patients who have absence of untreated radiculopathy or neurogenic claudication (except for 
radiculopathy caused by facet joint synovial cyst) and when there is no non-facet pathology per clinical 
assessment or radiology studies that could explain the source of the patients pain, including but not limited to 
fracture, tumor, infection, or significant deformity. The enrollee does not meet criteria and therefore, the 
request is deemed not medically reasonable or 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 medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 12, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on November 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on March 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that you feel this claim was wrongly rejected. The Plan 
denied your request. The Plan says that the provider is not a certified Medicare provider. 
 
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 or a certified Medicare provider. 
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 physical therapy 
services provided on March 29, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchodilation responsiveness, spirometry (94060), 
plethysmography for determination of lung volumes (94726) and diffusing capacity (94729) provided on May 
18, 2021. 
 
You asked the Plan to pay for pulmonary procedures. You say that per your coding department, the claim is 
coded correctly. The Plan denied your request. The Plan says the billed procedure codes 94060, 94729, and 
94726 have a Physician Fee Schedule PC/TC indicator of 1 and the claim a POS of 21  Inpatient Hospital. The 
professional interpretation was furnished in the same payment locality from where the TC was furnished. We 
find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a 
diagnostic test must be separately billed with modifier  26 by the interpreting physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 94060, 94726, 94729 is not supported in the medical record. Specifically, the 
professional component and the place of service was not properly billed on this claim. Based on this 
information, we decided that Medicare rules for coverage of pulmonary procedures have not been met. 
Therefore, we decided that the Plan does not have to pay for bronchodilation responsiveness, spirometry 
(94060), plethysmography for determination of lung volumes (94726) and diffusing capacity (94729) provided 
on May 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 10, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2021. 
 
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 0037U 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 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the file shows 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 July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services billed for date of service 
December 6, 2021. 
 
You asked the Plan to pay for laboratory testing services. You say that the services at issue were a necessity for 
the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 laboratory testing services billed for 
date of service December 6, 2021. have been met. Specifically, medical documentation is not available in the case record to document the medical necessity of the services at issue. Therefore, we decided that the Plan does 
not have to pay for laboratory testing services billed for date of service December 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 outpatient mental health services provided on 
March 16, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on February 10, 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 that the testing is not covered. 
 
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 references Local Coverage Article (LCA) A53628 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC genetic testing rendered on February 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Next Generation Sequencing (NGS) testing provided to the 
enrollee on October 26, 2020. 
 
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan 
denied your request. The Plan says the enrollee does not have a diagnosis that allows coverage for this testing. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. Maximus 
reviewed the FDA approval notice for this test. The FDA approval guidelines indicate this test is only approved 
for non-small cell lung cancer and prostate cancer. Based on the medical records and codes provided, the 
enrollee does not meet the diagnosis criteria. Medicare rules for coverage of this testing have not been met. 
Therefore, we decided that the Plan does not have to pay for Next Generation Sequencing (NGS) testing 
provided to the enrollee on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372, therapeutic, prophylactic, or 
diagnostic injection, billed for date of service February 1, 2022. 
 You asked the Plan to pay for procedure code 96372. You say that you submitted medical records. You are 
requesting the Plan to reconsider and pay the additional payment on this claim. The Plan denied your request. 
The Plan says payment for code 96372 is bundled into payment for code 95117. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 96372 
is a column II code to column I code 95117. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 96372, therapeutic, prophylactic, or diagnostic 
injection, billed for date of service February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70496-26 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 70496-26. You say that the medical records support payment. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 1, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for procedure code 70496-26 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70496-26 billed for date of service 
March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment; other than spine (98943) 
and an office visit (99202) provided by a chiropractor on May 23, 2022, and May 24, 2022. 
 
You asked the Plan to pay for manipulative treatment other than spine and an office visit. The Plan denied your 
request. The Plan says other services performed by a chiropractor are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulative treatment; other than spine (98943) and an office 
visit (99202) provided by a chiropractor on May 23, 2022, and May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87798, 87653, 87641, 87640, 87481, 
and 87150 billed for date of service May 6, 2021. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, there is no documentation 
which organisms are represented by the billed code. 
 
You asked the Plan to pay for procedure code 87798, 87653, 87641, 87640, 87481, and 87150. You say that 
you disagree with the denial. The Plan denied your request. The Plan says payment for codes 87798, 87653, 
87641, 87640, 87481, and 87150 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87798, 87653, 87641, 87640, 87481, and 87150 are column II codes to column I code 87801. Given that code 
87801 is not covered, the column II codes are also not supported.  
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87801, 87798, 87653, 87641, 87640, 87481, and 87150 billed for date 
of service May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for needle placement provided on  
May 2, 2022, and May 4, 2022. 
 
You asked the Plan to pay for ultrasonic guidance for needle placement. The Plan denied your request. The 
Plan says the provider did not submit the medical records. 
 
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 ultrasonic guidance for needle 
placement provided on May 2, 2022, and May 4, 2022. have been met. Therefore, we decided that the Plan 
does not have to pay for ultrasonic guidance for needle placement provided on May 2, 2022, and May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the submitted documentation is lacking regarding reasonably detailed findings 
supporting that the spinal vertebral bodies are the overwhelming primary generators of the enrollee's chronic 
pain. The documentation does not support formal surgical ablation of pre-designated basivertebral nerves as 
being 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided on 
April 12, 2022. 
 
 
 You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says this service is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
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 FoundationOne CDx (F1CDx) test 
(0037U) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on April 29, 2022, by an 
out-of-network (OON) provider.