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

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month, (e.g., tens, 
nmes) (CPT code A4595) provided on January 29, 2022. 
 
You asked the Plan to pay for the item. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are considered experimental and investigational. 
 
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 pay for the item. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the treating practitioners office records do not specifically document need for the 
transcutaneous electrical nerve stimulator supplied on January 29, 2022. 
 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 item have not been met. Therefore, we decided that the Plan does not have 
to pay for electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) (CPT code A4595) provided on 
January 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on October 21, 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 that the code is not eligible for payment. 
 
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 anesthetist in this case was a physician and certified registered nurse 
assistant. The plan has not given a rationale for why this provider type is not appropriate for these services. The 
provider stated that they sent in a provider registry form to confirm the provider's status, but the plan did not 
provide this to MAXIMUS for review. Therefore, we decided that the Plan has to pay for anesthesia services 
provided to the enrollee on October 21, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service January 24, 
2022. 
 You asked the Plan to pay for procedure code 76770. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76770 is bundled into payment for 
code 93976. 
 
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 76770 
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 procedure code 76770 billed for date of service January 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2750, V2781) purchased on February 10, 
2022. 
 You asked the Plan to pay for the eyeglasses. You say that this claim should be reprocessed to pay the full $200 
from the Plan's allowed amount for these eyeglasses. The Plan denied your request. The Plan says this claim 
was processed correctly and in accordance with your contract. 
 
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 these services up to a $200 retail price once per year. 
 
We looked at the file and the Plan's rules. The retail price of these eyeglasses was $305. Once your Plan 
benefits were applied, you were responsible for $84. Based on this information, we decided that you have been 
asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does 
not have to pay an additional amount for the eyeglasses (V2750, V2781) purchased on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L1686, L2624) provided December 13, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed orthosis. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis (L1686, L2624) 
provided December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for massage therapy. 
 
You asked the Plan to provide coverage for massage therapy. You say that you would like to try a less invasive 
method of therapy before attempting injections into your upper spine near your lungs in an attempt to manage 
your pain as well as reduce inflammation. The Plan denied your request. The Plan says massage therapy when 
performed by a licensed massage therapist is not covered under any condition. This is a non-covered benefit 
and authorization cannot be approved. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to provide coverage for massage therapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 18, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705.  
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed appropriately by 
Medicare coding regulations. 
 
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 the abdominal ultrasound (76705) provided on January 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the following drugs you were provided from July 28, 2021, 
to July 31, 2021: Amlodipine, Famotidine, Sennosides, Losartan, Mirtazapine, multivitamins, 
Hydrochlorothiazide, Zolpidem, and Alrazolam. 
 
You asked the Plan to pay for Amlodipine, Famotidine, Sennosides, Losartan, Mirtazapine, multivitamins, 
Hydrochlorothiazide, Zolpidem, and Alrazolam. You say that there is no way that these medications cost this 
much. The Plan denied your request. The Plan says self-administered drugs are not covered under your medical 
benefits. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the following drugs you were 
provided from July 28, 2021, to July 31, 2021: Amlodipine, Famotidine, Sennosides, Losartan, Mirtazapine, 
multivitamins, Hydrochlorothiazide, Zolpidem, and Alrazolam.  
 
Benefits for Amlodipine, Famotidine, Sennosides, Losartan, Mirtazapine, multivitamins, Hydrochlorothiazide, 
Zolpidem, and Alrazolam may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high frequency chest wall oscillation (HFCWO) system, 
includes all accessories and supplies (CPT code E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation system. You say that the enrollee 
needs this device to help their breathing. The Plan denied your request. The Plan says the notes they have 
received shows that the enrollee has a specific condition based off computed tomography (CT) imaging of the 
chest. The Plan states the notes do not show that they have damaged lungs, cystic fibrosis, or a specific 
condition that affects the functioning of the enrollee's brain, spine or nerves. 
 
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 high frequency chest wall 
oscillation system. Our physician reviewer found HFCWO is considered not medically necessary.  This 
enrollee has chronic obstructive pulmonary disease (COPD). There is no diagnosis of bronchiectasis, cystic 
fibrosis, or neuromuscular disease affecting diaphragm function. A clinical note addendum dated May 19, 
2022, indicates the enrollee has tried and failed other airway clearance methods, but there is no mention of 
flutter valve, and there are no other notes documenting trials of chest physiotherapy or flutter valve. Medicare 
does not cover this device for the treatment of COPD. The denial is upheld. 
 
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 high frequency chest wall oscillation system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve high frequency chest wall oscillation (HFCWO) system, 
includes all accessories and supplies (CPT code E0483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 19, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for neuroplasty services (64712-59 and 64708) provided on November 22, 
2021. 
 
You asked the Plan to pay for neuroplasty services. You say that this was billed correctly. The Plan denied your 
request. The Plan says that these codes are included in code 27364. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   In 
this case, the CPT Code Manual definition of code 64712-59 is neuroplasty, major peripheral nerve, arm or leg, 
open; sciatic nerve, and 64708 is neuroplasty, major peripheral nerve, arm or leg, open; other than specified. 
 
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 neuroplasty services. Our reviewer says that these codes are 
supported and separately payable. Our reviewer found adjacent tissue transfer, flaps, and grafts may be 
reported separately when all the technical aspects of these closure procedures have been performed. The 
records support that codes 64712 and 64708 were performed separately from the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuroplasty services have been met. Therefore, we decided that the Plan has to 
pay for neuroplasty services (64712-59 and 64708) provided on November 22, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you are requesting the claim to be processed as 
an in-network provider. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there are in-network providers within a reasonable distance from the enrollee. 
 
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 dental services provided on December 20, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient compression stockings identified with code 
A6530 that were issued on October 12, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
non-covered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate for you, it does not fall into a covered benefit category and cannot be 
paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the gradient 
compression stockings identified with code A6530 that were issued on October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an internal penile implant for the enrollee. 
 
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information about a trial of alternative treatments, such as a vacuum erection 
device, intraurethral medication, or intracavernous injections. 
 
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 implant. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found penile prosthesis implant surgery is a well-established option for the treatment of erectile dysfunction 
according to the current guidelines. However, treatment with a penile prosthesis is usually underatken if there 
has been failure or intolerance to other treatments such as oral medications(Viagra, Cialis, Levitra), vacuum 
erection devices, penile injections(Edex, Caverject), or urethral suppositories (Muse). The records do not show 
that the enrollee has tried an alternative treatment such as a vacuum erection device, intraurethral medication or 
intracavernous injections. As such, a penile implant in this case is not medically reasonable and 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 the implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an internal penile implant for the enrollee.