Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network dialysis services provided to the enrollee 
from February 1, 2022, to February 28, 2022. 
 
You asked the Plan to pay for these services. You stated that when you called the Plan you were told if you 
submitted a request for payment, it would be covered by the Plan. The Plan denied your request. The Plan says 
the records provided do not indicate the enrollee had prior authorization or that services were not available in 
network. The records also do not show the enrollee was out of the area. 
 
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 Plan must follow Medicare rules. Medicare allows Plans to require prior authorization for services. The 
Plan contract states enrollees must use network providers unless given prior authorization or if the network is 
not available. In this case, the enrollee was not out of the area and did not have prior authorization for dialysis  
services out of network. The Plan had network providers available to treat the enrollee.  Therefore, we decided 
that the Plan does not have to pay for out of network services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided 
February 16, 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 does not meet 
Medicare NCD/LCD criteria. 
 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 FoundationOne CDx (F1CDx) test 
(0037U) provided February 16, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 tests received on December 30, 2021. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you feel the notice was very confusing as to 
when and what is covered. The Plan denied your request. The Plan says the items received were not a covered 
benefit for this date of service. 
 The Plan must follow Medicare rules. The rules say that COVID-19 at home tests are covered from the Plan 
effective February 1, 2022. 
 
We looked at the file and Medicare rules. Review of the file shows that you received these tests on December 
30, 2021. The Plan did not cover these tests until February 1, 2022. This means you received these tests before 
the date of coverage for the tests actually started. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 tests have not been met. Therefore, we decided that the Plan does not have to pay 
for the COVID-19 tests received on December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging (78070). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no indication you have a disorder of the parathyroid gland 
which would substantiate the need for this study. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. You have kidney and 
prostate cancer. Calcium levels were elevated. Parathyroid planar imaging (78070) was requested. However, to 
support this imaging, an elevated parathyroid hormone would be needed and was not provided in the 
documentation available for review at this time. Our physician reviewer found that your condition does not 
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve parathyroid planar imaging (78070).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 2, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes the 
FANCC gene, the denial is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with prostate cancer. The FDA 
approval notice indicates that this panel is approved for prostate cancer. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on February 2, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network dialysis services provided to the enrollee 
from March 1, 2022, to March 23, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee was not out of area; prior authorization was not given and 
there were services available 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 provider in this case is not a network provider with the Plan. 
The Plan had network providers available who could have provided the services at issue in this appeal. The 
Plan did not pre-approve out of network care.   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 out of network dialysis services provided to the enrollee from March 1, 2022, to 
March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81185, 81286, 81400, 81413, 
81414, 81442, and 81479 provided on May 27, 2021.  
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation is missing required information to support the 
services billed. 
 
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. 
 
Review of the file shows that a test requisition and medical records were not submitted to support the services 
billed. This means that the documentation does not support that the laboratory testing at issue in this appeal was 
not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
This means the services are not payable as billed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services coded 81185, 81286, 81400, 81413, 81414, 81442, and 81479 provided on May 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 26, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that you have attached medical records for review. 
The Plan denied your request. The Plan says a valid referral was not found on file and the enrollee's services 
were not urgent or emergent in nature. 
 
  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 chiropractic services provided on January 26, 
2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 6, 2021 billed 
with code 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Although this one code was submitted on its own on a separate claim form, the other codes were 
submitted on a different claim form and the testing was performed on the same specimen. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 6, 2021 
billed with code 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are contracted with the facility where 
the enrollee resides, and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering and referring providers are both OON providers and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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 laboratory services provided on April 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG), duplex scan, and ultrasounds 
provided on January 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an ECG, duplex scan, and ultrasounds. You say that the services provided is for 
preventive medical procedure and you would like the Plan to pay for them. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 electrocardiogram (ECG), duplex scan, and 
ultrasounds provided on January 28, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization (37225, 37226, 37227, 37228) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that without this procedure the enrollee will not be 
able to function properly. The Plan denied your request. The Plan says that records do not show the enrollee 
has tried and failed supervised exercise therapy (SET) or has tried and failed conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The patient has 
satisfactory documentation of lifestyle limiting symptoms attributable to his lower extremity arterial occlusive 
disease despite conservative efforts. These findings are supported by an abnormal ankle brachial index on the 
left and evidence of proximal left superficial femoral artery disease on duplex. Our physician reviewer found 
that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve revascularization (37225, 37226, 37227, 37228) for the enrollee.  
 
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 the laboratory services coded 81479 provided on January 3, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 81479 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on March 11, 2021 and October 6, 2021. The billed date of service shows 
January 3, 2022. This means the date of service billed is incorrect. 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 coded 81479 provided on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
March 15, 2022, to March 21, 2022, and an outpatient hospital observation provided from April 01, 2022, to 
April 02, 2022. 
 
You asked the Plan to waive the copayments for an inpatient hospital stay and an outpatient hospital 
observation. You say that you had terrible care, and that is why you had to stay in the hospital longer, therefore, 
you feel you should not need to pay these large copayments. They are causing a financial hardship. The Plan 
denied your request. The Plan says the copayments applied were correct. 
 
 
 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 $375 
copayment each day for days 1 to 5 for inpatient stay, and a $300 for outpatient observation for inpatient 
hospital care and outpatient hospital observation ($375 x 5 = $1875 and $300 for outpatient observation = 
$2175). 
 
You have been asked to pay a $1875 copayment for 5 days of an inpatient stay, and a $300 for outpatient 
observation for an inpatient hospital stay and an outpatient hospital observation ($1875 + $300 = $2175). An 
inpatient hospital stay and an outpatient hospital observation falls within the Inpatient Hospital Care and 
Outpatient Hospital Observation benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
an inpatient hospital stay provided from March 15, 2022, to March 21, 2022, and an outpatient hospital 
observation provided from April 01, 2022, to April 02, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pigmented lesion assay rendered on January 21, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that pigmented lesion assays must be billed with the 
required DEX-Z code. 
 We looked at the file and Medicare rules. The file shows that the testing was not billed with the appropriate 
DEX-Z code. 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 pigmented lesion assay rendered 
on January 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan provided on 
April 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an LDCT scan. You say that radiology does not obtain authorization. The Plan 
denied your request. The Plan says the provider is not a network provider, and the services were not urgent or 
emergent, nor were they approved of 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 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 a low dose computed tomography (LDCT) scan 
provided on April 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PureWick system provided from July 22, 2021, to 
November 22, 2021. 
 
You asked the Plan to pre-approve the PureWick system. You say that the PureWick system was medically 
necessary. The Plan denied your request. The Plan says the PureWick system is not medically necessary. 
 
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 PureWick system. Our reviewer 
says that the PureWick system is not considered medically reasonable and necessary. Our physician reviewer 
found that there are no peer-reviewed articles published in the medical literature specific to the PureWick 
system, or external urinary collection system using a continuous low-pressure pump. Thus, there is no evidence 
to show the PureWick system to be an effective alternative in managing urinary incontinence. 
 
 
 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 PureWick system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the PureWick system provided from July 22, 2021, to November 22, 2021.