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

 
We decided that the Plan does not have to pay for an office visit provided on July 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 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 office visit provided on July 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Maximus reviewer did not consider that this enrollee was walking by himself using a
walker, and the plan was to be discharged home with either home health or outpatient therapy and did not
appear to require either visits with a rehab physician three times a week, or an interdisciplinary team to manage
his care.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary.
Based on the medical records provided, at the time of the appeal, the enrollee did not require an IRF level of
care and did not meet all of the required Medicare criteria for coverage of IRF services. Therefore, we decided
that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and
services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found continued care in the acute hospital is appropriate until the enrollee is stable to 
transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a 
skilled nursing facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 19, 2022, billed 
with codes 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says a panel constitutes a single procedural service, so one CPT code must be submitted 
for the panel. 
 
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. 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 February 19, 2022, billed with codes 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, and 
0033U.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal aorta ultrasound provided to the enrollee on 
May 16, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that this should be paid for. The Plan denied your 
request. The Plan says this was not reported with appropriate diagnosis codes.  
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 ultrasound. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no further history for the enrollee to provide details complying with Medicare rules. In 
particular, no smoking history is given, no documented family history, or other history to document the 
necessary. Age alone is not sufficient to satisfy the guidelines. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for an abdominal aorta ultrasound provided to the enrollee on May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the F1CDx testing provided on May 9, 2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the F1CDx testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the F1CDx testing provided on 
May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 24, 2020. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and a heavy-duty 
extra wide hospital bed (E0301). 
 
You asked the Plan to pre-approve a total electric hospital bed and a heavy-duty extra wide hospital bed. You 
say that the enrollee is bed ridden since 2016 and suffers from congestive heart failure and arthritis. The 
enrollee is unable to take care of herself. Most of her limbs are not usable due to inactivity and swelling. Her 
husband was her primary care giver until a recent injury. Doctors have suggested a bed like this would ease her 
discomfort to make her more independent. She is on pain killers and her circulation is very poor. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for a heavy-duty hospital bed as her 
last recorded weight falls short of the threshold of 350 pounds. A total electric hospital bed is not a covered 
item because the height adjustment feature is considered a convenience feature. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 
Medicare rules also say a heavy duty extra wide hospital bed is covered if the enrollee weight is more than 350 
pounds. 
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Medicare rules say that a heavy duty extra wide hospital bed is covered if the enrollee 
meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds 
but does not exceed 600 pounds. The records show that your last recorded weight was 255 pounds. The 
enrollee does not meet the coverage criteria for a heavy-duty hospital bed due to her weight being under 350 
pounds. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) 
and a heavy-duty extra wide hospital bed (E0301).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF care was medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not
met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply
the correct criteria. The Plan noted that the Maximus reviewer did not consider that this enrollee's ability to
participate in intensive therapy was described as limited by the hospital physical therapist, and that the enrollee
did not require physician supervision by a rehabilitation physician at least 3 days per week.
The Plan is correct in this case. 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.
Based on this information and the medical records, the Medicare rules for coverage of IRF care were not met at
the time of the appeal. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 25, 2022, to April 23, 2022. 
 
You asked the Plan to pay for home health services. 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 certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an 
appropriate NOA claim was not submitted for the period of care billed. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from March 25, 2022, to April 23, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from April 28, 
2022, to May 27, 2022. 
 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 the Notice of Admission (NOA) is required to process the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider did not send in a Notice of Admission (NOA) for these services.. Therefore, we decided that the Plan 
does not have to pay for home health services provided to the enrollee from April 28, 2022, to May 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says you were evaluated for a syncopal episode, and refused all options of care, including 
transportation. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 25, 2022. The record shows that you 
denied transportation to the hospital. The ambulance benefit is a transportation benefit. When there is no 
transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan 
does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 
25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99354, 99327) provided on July 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization 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 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 home health services (99354, 99327) provided on 
July 12, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 18, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies (A4349, A4358, A4357) provided on July 
5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical supplies. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the items denied correctly as they were non-
emergent and prior authorization 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 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 medical supplies (A4349, A4358, A4357) 
provided on July 5, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99327) provided on August 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization 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 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 rest home visit (99327) provided on August 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on June 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chronic care management services. You say that this is a participating provider. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and the 
services were not referred by a network provider. 
 
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 chronic care management services provided on 
June 3, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Therapeutic procedures (97110) provided on May 23, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapeutic procedures. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization 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 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 Therapeutic procedures (97110) provided on May 
23, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76377 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 76377. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says payment for code 76377 is bundled into payment for 
code 77063. 
 
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 76377 
is a column II code to column I code 77063. 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 76377 billed for date of service April 5, 2022.