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

 
We decided that the Plan does not have to pay for laboratory services (G0483, 80307) provided on February 9, 
2021. 
 
You asked the Plan to pay for laboratory services. You say that these services are necessary and are supported 
as billed. The Plan denied your request. The Plan says there is insufficient information to support the medical 
necessity of these services. 
 
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 services have been met. 
Specifically, the medical records provided do not include a signed physician order or any physician notes to 
support that this test was medically necessary and ordered by the enrollee's treating physician. Therefore, we 
decided that the Plan does not have to pay for laboratory services (G0483, 80307) provided on February 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service September 
21, 2022. 
 
You asked the Plan to pay for procedure code 99253. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a center mount 
modular footplate extension component (K0108), a manual swingaway, retractable or removable mounting 
hardware for joystick (E1028x3), and a lateral trunk or hip support, any type, including fixed mounting 
hardware (E0956). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the seat elevator does not 
serve a primary medical purpose and is statutorily non-covered. The footplate component is incorrectly coded 
and unbundled. The Plan also says the manual swingaways and the lateral trunk or hip support hardware are 
duplicate services and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose. The rules also say Medicare covers DME only when it is reasonable and necessary. If DME serves the 
same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare rules confirm that a seat elevation system does not serve a 
primary medical purpose and is not a covered benefit. The records show that the footplate component is 
incorrectly coded and unbundled, therefore, not a covered benefit. The records also show that the manual 
swingaways and the lateral trunk or hip support are duplicate services. These items have already been approved 
and duplicate items are not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power seat elevation system (E2300), a center mount modular footplate extension component 
(K0108), a manual swingaway, retractable or removable mounting hardware for joystick (E1028x3), and a 
lateral trunk or hip support, any type, including fixed mounting hardware (E0956).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) and progressive lenses 
(V2781) provided on February 11, 2022. 
 
You asked the Plan to pay for polycarbonate lenses (V2784) and progressive lenses (V2781). You say that you 
are requesting reimbursement for a pair of glasses that you purchased after cataract surgery that was performed 
on December 2, 2021, and December 16, 2021. The Plan denied your request. The Plan says use of 
polycarbonate or similar material are denied as a noncovered deluxe feature, and progressive lenses are denied 
as noncovered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses with standard frames after cataract surgery that implants an 
intraocular lens is provided. 
 
We looked at the file and the Plan's rules. The Plan rules say that the medical plan covers one pair of eyeglasses 
with standard frames after cataract surgery that implants an intraocular lens. The record shows that the denied 
services were not standard frames and lenses. Based on this information, we decided that the Plan's rules for 
coverage of polycarbonate lenses (V2784) and progressive lenses (V2781) have not been met. Therefore, we 
decided that the Plan does not have to pay for polycarbonate lenses (V2784) and progressive lenses (V2781) 
provided on February 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
March 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided to the enrollee on November 27, 2021.
You asked the Plan to pay for the laboratory testing. You say that these services were medically necessary and are supported in the medical records. The Plan denied your request. The Plan says that the specimen was collected during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided to the enrollee on November 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires further medical 
workup. The Plan denied your request. The Plan says the enrollee's needs are no longer of an acute nature. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services beyond February 19, 2023, were requested. 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 requested services. Our physician reviewer found that the enrollee was admitted 
with major depressive disorder with severe psychotic features, generalized anxiety disorder, and major 
neurocognitive disorder most likely due to Alzheimer's disease.  It is not expected this enrollee will improve in a reasonable period of time as the enrollee does not have suicidal 
or homicidal ideation, auditory or visual hallucinations. The enrollee is compliant with treatment while not 
showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that in the past, you have stopped breathing while 
sleeping. The Plan denied your request. The Plan says you have not failed BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our physician reviewer 
found that you have chronic hypercapnic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that you were successfully treated with BiPAP while in the hospital. The provided 
documentation does not contain sufficient detailed information to justify the treatment selected. You could be 
treated with a BiPAP machine. The Plan has indicated coverage for such a device is available upon request. 
The elements of the coverage criteria 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressing on 
tooth #19 (D7922). 
 
You asked the Plan to pre-approve the placement of intra-socket biological dressing on tooth #19 (D7922). You 
say that the dentist created the dentures backwards and they do not fit in your mouth. You say D7922 is 
showing that it is not a covered service. The Plan denied your request. The Plan says the 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 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 pre-approve the 
placement of intra-socket biological dressing on tooth #19 (D7922).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain onlay restoration (D2643) for tooth #12 provided 
on February 21, 2022. 
 
You asked the Plan to pay for the dental service. You say that there are no network providers in your service 
area and thought the dental procedure would be covered. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the porcelain onlay restoration is not covered by the 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 a 
porcelain onlay restoration (D2643) for tooth #12 provided on February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the accessory for speech generating device, not 
otherwise classified (E2599). 
 
You asked the Plan to pre-approve the speech generating device accessory. You say that the enrollee is unable 
to call for help or verbalize concerns without this medically necessary equipment and accessories. The Plan 
denied your request. The Plan says this item 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. Based on this information, we decided that Medicare rules for coverage of the speech generating device accessory have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the accessory for speech generating device, not otherwise classified (E2599).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing (G0483, 80307) provided on September 19, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that there was insufficient information to verify medical necessity of this 
testing. 
 
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 indicated that progress notes were needed to review the claim. The 
Plan failed to provide documentation showing that requests were sent to the provider for this missing 
information. Thus, we cannot confirm that the Plan made reasonable and diligent efforts to gather and forward 
for our review. Therefore, we decided that the Plan has to pay for the drug testing (G0483, 80307) provided on 
September 19, 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 procedure code 87660 billed for date of service July 20, 
2021. 
 
You asked the Plan to pay for procedure code 87660. You say that this service was medically necessary and 
was reported correctly. The Plan denied your request. The Plan says this service is not supported as billed, as 
the procedure code is inconsistent with the enrollee's gender. 
 
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 87660 is infectious agent detection by nucleic acid (DNA 
or RNA); Trichomonas vaginalis, direct probe technique. 
 
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 procedure code 87660. Our reviewer says that this service is 
not supported as billed. Our reviewer found that the medical records provided do not include sufficient 
information to verify that the use of this gender specific code was appropriate for the services performed on 
July 20, 2021; therefore, this code cannot be verified, and no additional reimbursement is allowed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87660 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87660 billed for date of service July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of HBO therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not indicate that the enrollee has a wound classified as Wagner grade III or higher. The 
review has determined that the enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of HBO therapy (99183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
August 16, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for codes 87481 and 87653 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 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service August 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right hip capsulectomy or capsulotomy with or without 
excision of heterotopic bone with release of hip flexor muscles (27036). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you believe it is medically necessary 
for the enrollee to undergo a right total hip arthroplasty at this time. The Plan denied your request. The Plan 
says this procedure is considered experimental and unproven as there is not enough medical proof that shows 
the safety and/or success of this procedure. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve right hip capsulectomy or capsulotomy with or without excision of heterotopic bone with release of 
hip flexor muscles (27036).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had high risk findings on a stress test. 
 
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 the requested services. Our physician 
reviewer found that the enrollee has a history of chest pain. The enrollee had a negative non-invasive work-up, 
including normal radionuclide stress test in December 2022. Guidelines do not support a need for invasive 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this enrollees clinical management. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization services.