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

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on January 19, 
2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight psychotropic test (81479) provided October 25, 
2021. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration as the test was 
medically necessary. This appeal should be approved and paid at the established rate. The Plan denied your 
request. The Plan says GeneSight psychotropic has not been shown to be useful and is not covered by 
Medicare. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
GeneSight psychotropic test (81479) provided October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing 
(CPT)code(s): 81286-XS x1, 81238-XS x1, 81410-XS x1, and 81411-XS x1) provided on April 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as 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. 
 
The documentation submitted on appeal indicates the cardiovascular genetic screening panel was initiated by 
the laboratory and not by the enrollee's treating physician. Therefore, we decided that the Plan does not have to 
pay for cardiac risk assessment genetic screening testing (CPT)code(s): 81286-XS x1, 81238-XS x1, 81410-XS 
x1, and 81411-XS x1) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6539. 
 
You asked the Plan to pre-approve the compression stockings. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not a covered benefit under Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 
 Although this item may be appropriate, 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 pre-approve compression 
stockings identified with code A6539.
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 LTACH can provide the level of care 
needed for this enrollee. The Plan denied your request. The Plan says all services that would be provided in the 
LTACH are being provided in the current acute care setting which is already approved. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation and management service provided on 
February 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a telephone evaluation and management. You say that most of your employees 
were sick and it was not possible for you to get the authorization before the services were rendered. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and based on the 
documentation submitted, they have determined that the services 
 
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 telephone evaluation and management service 
provided on February 21, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that there is sufficient science published in 
peer-reviewed publications. You say that this procedure improves the quality of life in patients suffering from 
vertebrogenic low back pain. You say that the Intracept procedure, not just the device received initial FDA 
clearance, which means the procedure is safe and effective. The Plan denied your request. The Plan says 
medical studies have not proven that the requested service is helpful for treatment of the enrollee's health 
problem. 
 
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 an Intracept procedure. Our reviewer 
says that an Intracept procedure not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental and investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a StimQ peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the peripheral nerve stimulator. You say that this should be approved to help 
treat your chronic pain. The Plan denied your request. The Plan says this device is not shown to be 
safe/effective treatment for your condition. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this 65-year-old enrollee has chronic bilateral back pain. She has tried 
medications including anti-inflammatory drugs, opioids, and muscle relaxants. She has had nerve blocks. The 
request is for placement of a StimQ Peripheral nerve stimulator. 
 
StimQ is considered experimental/ investigational for low back pain. Therefore, the request is considered not 
medically reasonable or 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 peripheral nerve stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a StimQ peripheral nerve stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to 
home or nursing home (CPT code R0070) provided on July 16, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The provider reported transportation of portable radiology equipment but did not report setup codes which does 
not follow industry standard coding rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
transportation of portable x-ray equipment and personnel to home or nursing home (CPT code R0070) provided 
on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology, in situ hybridization (eg, FISH), urinary 
tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) 
provided on April 21, 2021. 
 You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as 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. 
 
The services are not authorized because code 88120 is not a Medicare benefit for the diagnosis listed on the 
claim (N39.9- Disorder of urinary system) and is done for screening purposes. Cystoscopy in conjunction with 
bladder tumor markers is standard practice to evaluate patients with symptoms suggesting bladder cancer and 
to monitor treated patients for recurrence or progression. Bladder cancer tumor markers performed by any 
technology immunoassay, molecular or FISH testing, are not covered for screening of all patients with 
hematuria. Bladder tumor markers are not expected to be performed until other diagnostic studies fail to 
identify the etiology of the hematuria. Urine cytology is not considered a bladder tumor marker. Therefore, we 
decided that the Plan does not have to pay for the cytopathology, in situ hybridization (eg, FISH), urinary tract 
specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) 
provided on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on October 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 74230 is "Radiologic examination, swallowing function, 
with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when 
performed, contrast (eg, barium) study." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider is reporting portable 
x-ray services provided to enrollee while in nursing home. This situation is not covered. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services provided to the enrollee on October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 services are not medically necessary Our physician reviewer found the enrollee has postmenopausal 
osteoporosis. She has not tried and failed the Plan's require drugs, an oral bisphosphonate and zoledronic acid. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, the Prolia 
is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory failure therapy rendered on November 2, 
2021 to November 30, 2021. 
 
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 diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis 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 respiratory failure 
therapy rendered on November 2, 2021 to November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2021. 
 
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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mastectomy sleeve provided on 
December 22, 2021. 
 
You asked the Plan to waive the coinsurance for the mastectomy sleeve. You say that there was no prosthetic 
involved. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for each prosthetic device and related item, including mastectomy supplies.  
 
 
 You have been asked to pay $23.62, which is 20% of the allowed amount for the mastectomy sleeve ($118.12 
allowed amount x 20% coinsurance = $23.62). The mastectomy sleeve falls within the Prosthetic Devices and 
Related Supplies benefit category. Please note that this category relates to all mastectomy supplies, in addition 
to prosthetic items. 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 coinsurance for a mastectomy sleeve provided 
on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 14, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
 
 
 
 We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the pelvis rendered 
on January 12, 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 procedure code 72192 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72192 
is a column II code to column I code 74177. 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 computed tomography (CT) scan of the pelvis rendered on 
January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the routine eye exam provided on 
September 28, 2021. 
 
You asked the Plan to waive the copayment for the routine eye exam. You say that you feel you should not be 
responsible for this cost share amount, and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a routine eye exam on the date of service at issue in this appeal. The 
Plan says the correct copayment has applied per your contract with the Plan. 
 
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. 
 
We looked at the file and the Plan's rules. The file shows that you received a routine eye exam on September 
28, 2021. You have been asked to pay a $20 copayment amount for the routine eye exam. The routine eye 
exam falls within the Vision care benefit category. This means that you have been asked to pay the correct 
amount. Therefore, we decided that the Plan does not have to waive the copayment for the routine eye exam 
provided on September 28, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on October 19, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says hearing aids 
must be provided through the Plans hearing provider in order to receive the hearing aids benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on 
October 19, 2021.