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

 
We decided that the Plan does not have to pay for procedure codes 99309 and 99308 billed for date of service 
December 11, 2021, to December 22, 2021. 
 
You asked the Plan to pay for procedure codes 99309 and 99308. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the number of units of code 99309 billed exceeds 
the maximum allowed. Payment for code 99308 is bundled into code 99309. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that claims submitted 
where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99309 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. We have confirmed that code 99308 is a column II code to column I code 99309. 
Code 99308 has not been billed with an appropriate modifier to bypass the edit. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99309 and 99308 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99309 and 99308 billed for date of service 
December 11, 2021, to December 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on August 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. 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 looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that an invalid NOA with an admission 
date of August 21, 2015, was received on April 18, 2022. Therefore, we decided that the Plan does not have to 
pay for the home health services provided on August 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet medical necessity guidelines for admission to an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76815 billed for date of service August 12, 
2022. 
 
You asked the Plan to pay for procedure code 76815. You say that you are appealing with records. The Plan 
denied your request. The Plan says payment for code 76815 is bundled into payment for code 76821.  
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 76815 
is a column II code to column I code 76821. 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 76815 billed for date of service August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering and interpretation rendered on May 17, 
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 are not covered. 
 
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 these services.  
 
We looked at the file and Medicare rules. There is no documentation to support that the 3D rendering and 
report was necessary for the imaging. 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 3D 
rendering and interpretation rendered on May 17, 2022.  
 
Local Coverage Determination (LCD) L33256 referenced by the Plan is not valid for the state of Georgia and 
was not used in the MAXIMUS determination.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. 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 one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 radiofrequency ablation to the SI joint. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found this is 
considered experimental/investigational because of the wide variation in efficacy reported in the literature. 
Therefore, the request is deemed 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGMs). 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor (CGMs). You say that it would be 
beneficial for you to have a continuous glucose monitor (CGM). The Plan denied your request. The Plan says 
you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM. have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you meet the criteria to get the meter. The Plan 
denied your request. The Plan says the enrollee's treatment regimen is not being frequently adjusted by the 
enrollee; therefore, the Medicare criteria for a CGM were not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
  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 CGM. Our reviewer says that the 
CGM is not medically necessary. Our physician reviewer found that the provided records document the 
enrollee is insulin treated with three or more daily administrations of insulin (Levemir once daily and Lispro 
three times daily). The records do not document the enrollee's insulin treatment regimen that requires frequent 
adjustment by the enrollee on the basis of blood glucose monitor or CGM testing results. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home nursing services provided from July 13, 2022, to 
August 13, 2022. 
 
You asked the Plan to pay for nursing services. You say that unfortunately, Medicare certified health care 
agencies in your area were unable to provide services due to lack of personnel. The Plan denied your request. 
The Plan says this provider is not certified by Medicare so is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must be enrolled in the Medicare 
program to receive payment for covered services.  
 
We looked at the file and Medicare rules. This provider is not enrolled in Medicare so is not payable. Based on 
this information, we decided that Medicare rules for coverage of nursing services have not been met. Therefore, 
we decided that the Plan does not have to pay for home nursing services provided from July 13, 2022, to 
August 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trospium chloride. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 pre-approve trospium chloride.  
 
Benefits for these services 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service September 
23, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 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 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 procedure code 76705 billed for date of service September 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you are appealing with records. 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, for 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 March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on September 09, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on September 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on August 24, 2022. 
 
You asked the Plan to waive the copayment for wound care. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $260 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $260 copayment for wound care. This item/service falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 copayment for wound care provided on August 
24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 27, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $395 
copayment for Outpatient surgery. 
 
You have been asked to pay a $395 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 copayment for outpatient surgery 
provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 13, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 26, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the colonoscopy provided on July 25, 
2022. 
 
You asked the Plan to waive the cost sharing for the colonoscopy. You say that you were told that this service 
would be covered in-network. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 20% 
coinsurance for an out-of-network diagnostic colonoscopy at an ambulatory surgical center or outpatient 
hospital setting. 
 
 
 
 You have been asked to pay a 20% coinsurance for the colonoscopy ($562.30 x .20 = $112.46) ($281.15 x .20 
= $56.23). This item/service falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 
cost sharing for the colonoscopy provided on July 25, 2022.