Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Sure Grip Feather hand control modification for an
automobile provided on January 21, 2021 and April 13, 2021.
You asked the Plan to pay for automobile hand control. You say that it seems strange that this provider would
not be Medicare certified, and you have difficulty getting your foot on your vehicle's brake pedal in a timely
manner so needed this control. The Plan denied your request. The Plan says the denial of payment for this
equipment is correct, because this provider is not Medicare certified and is not payable.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pay for Sure Grip Feather hand control modification for an automobile provided on January 21, 2021
and April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional gadoterate meglumine injections (A9575, A9575-
JW) provided on March 23, 2021.
You asked the Plan to pay for additional gadoterate meglumine injections. You say that the enrollee had
multiple exams. The Plan denied your request. The Plan says additional units are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that additional units of CPT codes A9575 and A9575-JW are not supported in the medical record. The
medical record only supports one unit each of CPT codes A9575 and A9575-JW, which were previously billed
and paid. Based on this information, we decided that Medicare rules for coverage of additional gadoterate
meglumine injections have not been met. Therefore, we decided that the Plan does not have to pay for
additional gadoterate meglumine injections (A9575, A9575-JW) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
July 30, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81238, 81410, 81411) provided May 12,
2021.
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan
denied your request. The Plan says the billed service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
genetic risk assessment panels.
We looked at the file and Medicare rules. The tests at issue were cardiovascular risk panels. These are non-
covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not
been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81238, 81410,
81411) provided May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional unit of Current Procedural Terminology (CPT)
71045 provided to the enrollee on August 17, 2021.
You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your
request. The Plan says the submitted documentation supports two units of CPT 71045.
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 71045 is "Radiologic examination, chest; single view."
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the additional unit. Our reviewer says that the services at
issue in this case were not supported by the medical records. Our reviewer found there is clear documentation
of two separate chest x-rays with different indications done on August 17, 2021.
We looked at this coder's review, the file, and Medicare rules. There is no evidence to support payment of more
than two units of CPT 71045. Based on this information, we decided that Medicare rules for coverage of the
additional unit have not been met. Therefore, we decided that the Plan does not have to pay for an additional
unit of Current Procedural Terminology (CPT) 71045 provided to the enrollee on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-
network (OON) provider on December 16, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on
December 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the
enrollee on July 26, 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 this code should not be unbundled.
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 70450 is a column II code to column I code 70496. 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 imaging services
(procedure code 70450) provided to the enrollee on July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (71045) provided July 30, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the billed code shares a bundled relationship with another code 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.
In this case, we have confirmed that code 71045 is a column II code to column I code 71046. 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 radiology services
(71045) provided July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from December 19, 2020,
through December 26, 2020.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says an
authorization was required from the medical group and was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services 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 an inpatient admission provided from December 19, 2020,
through December 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent screening testing provided on July 15, 2021.
You asked the Plan to pay for infectious agent testing. You say that you perform the testing ordered by the
referring physician. The Plan denied your request. The Plan says the denial of payment for this testing is
correct, because this testing is not covered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, infectious agent testing, was requested for screening purposes. Medicare does
not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for
infectious agent screening testing provided on July 15,2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the recliner chair (E1399) purchased April 10, 2021.
You asked the Plan to pay for the recliner chair. You say that you are requesting reimbursement for a power
lift/recliner chair because the enrollee has a heart condition and needs to keep legs and feet raised to keep from
swelling. The Plan denied your request. The Plan says this item is considered a convenience item and is not
covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the recliner chair (E1399) purchased April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office consultation (99244) provided on June 22, 2021.
You asked the Plan to pay for office consultation. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99244 is
not valid for Medicare purposes and is not payable.
The Plan must follow Medicare rules. Medicare rules say that code 99244 is not valid for Medicare purposes
and is not payable.
We looked at the file and Medicare rules. This code is not valid for Medicare purposes and is not payable.
Based on this information, we decided that Medicare rules for coverage of office consultation have not been
met. Therefore, we decided that the Plan does not have to pay for an office consultation (99244) provided on
June 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705) provided on August 9, 2021.
You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. The Plan denied
your request. The Plan says this is not separately payable.
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 76705
is a column II code to column I code 93976. 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 an ultrasound (76705) provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for ophthalmological services, medical
examination, a fundus photography with interpretation and report and an eye refraction provided on
July 1, 2021.
You asked the Plan to pay an additional amount for ophthalmological services, medical examination, a fundus
photography with interpretation and report and an eye refraction. You say that you should not have to pay
anything for these services. The Plan denied your request. The Plan says you are responsible for a $30.00
copayment for Medicare Covered Vision services by an In-Network. Since your Plan does not cover refraction,
frames and lenses, the Plan's vision provider covers all these under their Plan, which allowed $79.00 and the
member responsibility will be $39.00 for these services.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the ophthalmological services, medical
examination are covered with a $30 copayment. The file shows that the fundus photography with interpretation
and report and an eye refraction were pad with a $39 member responsibility. Therefore, we decided that the
Plan does not have to pay an additional amount for ophthalmological services, medical examination, a fundus
photography with interpretation and report and an eye refraction provided on July 1, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgical services provided on
May 14, 2021, and May 21, 2021.
You asked the Plan to waive the copayment for outpatient surgical services. You say that the services should be
covered as you were only there for five minutes. The Plan denied your request. The Plan says the cost-sharing
applied correctly based on the services provided
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 $325
copayment for Outpatient hospital services.
You have been asked to pay two $325 copayments for the outpatient surgical service visits provided on May
14, 2021, and May 21, 2021. The record indicates that these services were performed in an outpatient setting.
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 outpatient surgical services provided on May 14, 2021, and
May 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport (A0428, A0425) provided on July 6, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied
your request. The Plan says the ambulance transport was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for nipple/areola reconstruction surgery provided on
April 13, 2021.
You asked the Plan to pay for nipple/areola reconstruction. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because
the operative report does not include documentation of nipple/areola reconstruction.
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 19350 is nipple/areola reconstruction.
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 nipple/areola reconstruction. Our reviewer says that this code
does not meet criteria for payment. Our reviewer found the operative report does not indicate any type of graft
to reconstruct the nipples. Therefore, the coverage elements are not satisfied.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nipple/areola reconstruction have not been met. Therefore, we decided that the
Plan does not have to pay for nipple/areola reconstruction surgery provided on April 13, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that this is necessary. The Plan
denied your request. The Plan says the enrollee's needs are currently met in the IRF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who suffered a
stroke, current in acute inpatient rehabilitation. From a nursing perspective, the beneficiary received oral
medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received
physical, occupational, and speech therapy. The beneficiary was at a minimal to moderate assist level with bed
mobility and transfers. The beneficiary required varying assist with ADLs. He worked with speech therapy on
cognitive communication deficits. He tolerated a regular diet and thin liquids.
There are no identifiable skilled nursing service needs. There are no daily skilled therapy service needs. This
beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

Maximus Federal Services will then send your request form and the case file used to decide your appeal to the
OMHA office in your jurisdiction for review. Once this is done, any further communications regarding your
appeal will come directly from the OMHA office.
How we made our decision
1. We read all the papers in the file.
2. We checked Medicare rules.
3. We checked the contract with the Plan.
4. If required, we sent the file to a Maximus Federal Services physician reviewer.
To make our decision we read all the papers in the file very carefully. We used the Medicare rules. We looked
to see if the Plan correctly followed Medicare rules and regulations.
Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan
and the member. It is usually called the "Evidence of Coverage" (EOC) or "Member Agreement." We read this
contract carefully to see what the Plan is supposed to cover.
Medicare rules
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Explanation of decision
We decided that the Plan does not have to pay for chiropractic services (procedure code 99212) provided to the
enrollee from May 28, 2021 to June 7, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says the only covered chiropractic services is manual manipulation of the spine to correct a
subluxation.
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 services (procedure code 99212) provided to the enrollee from
May 28, 2021 to June 7, 2021