Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87086) provided on September 12, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed diagnosis 
is not appropriate for code 87086. 
 
The Plan must follow Medicare rules. Medicare rules say that National Coverage Determination 190.12 
provides a list of covered diagnosis codes for code 87086.  
 
We looked at the file and Medicare rules. Per NCD 190.12, diagnosis code C61 is not covered for code 87086. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services (87086) provided on September 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on August 17, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the records show that this panel tested for more than 5 
respiratory pathogens. Based on this information, we decided that Medicare rules for coverage of the 
respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory polymerase chain reaction (PCR) panel provided on August 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network emergency room (ER) 
visit provided on December 10, 2021. 
 
You asked the Plan to waive the copayment for an out-of-network emergency room (ER) visit. You say that 
you paid your copayment for this visit and should not owe anymore, in or out-of-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 a 
$1167.16 copayment for emergency care. 
 
You have been asked to pay a $1167.16 copayment for an out-of-network emergency room (ER) visit. This 
item/service falls within the emergency care 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. This visit was totaled at $7376, the facility adjusted the bill down to a 
balance of $1266. Having given credit for the $98.84 copayment made by the member, the remaining outstanding balance is $1167.16. Therefore, we decided that the Plan does not have to waive the copayment for 
an out-of-network emergency room (ER) visit provided on December 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the behavioral health services provided on May 11, 2022. 
 
You asked the Plan to pay for the behavioral health services. You say that the services should be covered. The 
Plan denied your request. The Plan says that prior authorization is required for this service. 
 
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. We are unable to confirm the service requires prior authorization as the Plan 
submitted the incorrect Evidence of Coverage. Therefore, we decided that the Plan has to pay for the behavioral 
health services provided on May 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter. 
 
MAXIMUS Federal Services read your letter and knows that you may have a question regarding your 
enrollment in the Plan.  MAXIMUS Federal Services cannot answer enrollment questions.  MAXIMUS Federal 
Services is sending a copy of your case file and your letter to the Philadelphia CMS Regional Office, so that it 
can look into your enrollment question.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62325 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 62325. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 62325 is bundled into payment for code 62368.  
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 62325 
is a column II code to column I code 62368. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 62325 billed for date of service September 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a positron emission tomography (PET) 
scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found this patient 
does not qualify for a PET scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26-76 billed for date of service March 
28, 2022. 
 You asked the Plan to pay for procedure code 76705-26-76. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76705-26-76 is 2. The MAI value for this code is 3. You billed 3 units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 76705-26-76 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705-26-76 billed for date of service March 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0012M) provided on September 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says insufficient information was provided to support the billed service. 
 
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 lab services have been met. 
Provided documentation included lab results and scientific literature. No clinical records were provided to show this test was medically necessary. Therefore, we decided that the Plan does not have to pay for lab 
services (0012M) provided on September 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97164 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 97164. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules 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 97164 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 97164 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97164 billed for date of service April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 28, 2022, to 
March 29, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of secondary diagnosis code E43. The Plan denied your request. The Plan 
says the medical records do not support the billing of secondary diagnosis code E43. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with E43. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the 
medical records do not support the billing of secondary diagnosis code E43. Our physician reviewer found 
Medscape Internal Medicine, Protein-Calorie Malnutrition (PCM) refers to a nutritional status in which 
reduced availability of nutrients leads to changes in body composition and function.  While reported to have 
been chronically ill-appearing with bitemporal wasting, the enrollee was described as having a normal weight. 
In this case there was no clinical or laboratory evidence to support this diagnosis. The review has determined 
that the documentation did not support secondary diagnosis code E43.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 28, 2022, to March 29, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 94761 billed for date of service 
September 18, 2022. 
 
You asked the Plan to pay for procedure codes 93005 and 94761. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure code 93005 is considered bundled and not separately 
payable and code 94761 is not payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 93005 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 93005 is not separately payable. Code 94761 has a status indicator of N on the Physician Fee 
Schedule and is non-covered. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 93005 and 94761 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 93005 and 94761 billed for date of service September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on July 
17, 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 Current Procedural Terminology (CPT) code 99223 (1 unit) remains not supported. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 examination was basic and 
was significant for normal neurological signs. The workup showed non-acute imaging and mild anemia. However, the documentation did not clearly show a comprehensive examination nor medical decision making 
of high complexity, but rather moderate complexity. Therefore, the code 99223 does not appear to be 
appropriate for this encounter. 
 
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 initial hospital care (procedure code 99223) rendered on July 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27096 billed with July 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that under the ambulatory surgical center (ASC) payment 
system, Medicare makes facility payments to ASCs only for the specific ASC covered surgical procedures on 
the ASC list of covered surgical procedures. 
 
We looked at the file and Medicare rules. Billed code 27096 is not an ASC-covered surgical procedure. 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 procedure code 27096 billed with July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder detect test (0012M) provided September 19, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you would appreciate prompt review of this 
information and authorization of coverage for the Cxbladder Detect test for this enrollee. The Plan denied your 
request. The Plan says this service does not meet coverage requirements as the Cxbladder Detect test is 
unproven at this time. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for Cxbladder detect test (0012M) provided September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
(87481, 87798) provided on December 16, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing is not experimental or 
investigational. The Plan denied your request. The Plan says this testing should be billed with a single panel 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase 
chain reaction (PCR) panel testing (87481, 87798) provided on December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the standard wheelchair (K0001) purchased 
September 2, 2022. 
 
You asked the Plan to reimburse you for the wheelchair. You say that if it would have been explained that the 
claim could be processed for a new wheelchair on a rental basis, you could have set up the chair that way. You 
followed all of the instructions, but the rental part was not part of that discussion. The Plan denied your request. 
The Plan says wheelchairs are a capped rental item.  
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 $425.99 
for Durable medical equipment (DME) and related supplies.  
 
You have asked for reimbursement of $425.99 for the wheelchair. This item/service falls within the Durable 
medical equipment (DME) and related supplies benefit category. Wheelchairs are a capped rental item. Capped 
rental items are not eligible for purchase. They are only allowed as rental items through qualified suppliers. 
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 reimburse you for the standard wheelchair (K0001) purchased September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft at time of implant placement (D6104). 
 
You asked the Plan to pay for a bone graft. You say that this bone graft is necessary for implants. The Plan 
denied your request. The Plan says the requested dental service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on November 14, 
2022. 
 
You asked the Plan to pay for the dental 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 do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
consultation (D9310) provided on November 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been 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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a history of osteoporotic fracture or a trial of drug zoledronic acid before they will approve the 
requested drug. The documentation does not support that the enrollee has a history of osteoporotic fracture or 
has tried and failed the required drug. The documentation does not support that zoledronic acid would likely be 
less effective and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).