Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for code 27447. We decided that the Plan does not have to pay for code 
20610.  
 
You asked the Plan to pay for coded 27447 and 20610. You say that you would like the Plan to reconsider their 
denial of payment. The Plan says that the services are not covered. 
 
We decided that the Plan has to pay for code 27447.  
 
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 27447 is Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without 
patella resurfacing (total knee arthroplasty). 
 
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 code 27447. Our reviewer says that the 
medical records support the billing of code 27447 provided on October 21, 2020. Our physician reviewer found 
the enrollee was being treated for unilateral primary osteoarthritis right knee; unilateral primary osteoarthritis, 
left knee. The operative report dated October 21, 2020 procedure details demonstrated degenerative changes 
involving all 3 compartments. There was significant loss of articular surface along with significant osteophytes. 
The procedure goes on to detail a total knee replacement having been performed on the bilateral knees. 
Therefore, the medical records do support the billing of arthroplasty, knee, condyle and plateau; medial and 
lateral compartments with or without patella resurfacing (total knee arthroplasty), CPT code 27447.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27447 have been met. Therefore, we decided that the Plan has to pay for 
code 27447.  
 
We also decided that the Plan does not have to pay for code 20610. 
 
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 20610 
is a column II code to column I code 27447. 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 code 20610. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The provided documentation does not clearly show that the enrollee has reached a new plateau in function. Daily skilled services are reasonable to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ranolazine for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ranolazine for the enrollee.
Benefits for this drug 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on June 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 71045
is a column II code to column I code 74022. 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 services (71045) provided on June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for air ambulance transport for the enrollee.
You asked the Plan to provide coverage for air ambulance transport. You say that air ambulance transport is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and says the request was for air transport
from Miami, Florida to Salem, Ohio. However, there were three facilities within the state of Florida and many
facilities closer than Salem, Ohio that could treat the enrollee.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that Medicare only pays for air
or ground transport to the nearest facility that meets the enrollee's medical needs if the enrollee cannot be
treated by the originating facility. The requested transfer destination was not the nearest facility that met the
enrollees needs. Therefore, we decided that the Plan does not have to provide coverage for air ambulance
transport for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330). 
 
You asked the Plan to pre-approve endodontic therapy. You say that the service is necessary. The Plan denied 
your request. The Plan says the requested 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 Plan's 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 pre-approve 
endodontic therapy (D3330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the handicap ramp and landing purchased on February 19,
2021, and March 12, 2021.
You asked the Plan to pay for the handicap ramp and landing. You say that this is a doctor ordered wheelchair
ramp and landing for their home. You state the enrollee was discharged in a wheelchair due to lower body
weakness. You state the treating physician ordered this to be installed so the enrollee could be safely
discharged to home. The Plan denied your request. The Plan says handicap ramps and landings are not a
covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
These services are considered to be home modifications and they are not covered by Medicare or the Health
Plan. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the handicap ramp and landing purchased on February 19, 2021, and March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 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 testing is 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 June 2, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the full cardiology genetic panel testing assay (Hereditary 
Cardio screen - 117 Genes) (CPT code(s): 81408 X 2, 81407 X 1, 81406 X 2, 81405 X 2, 81404 X 2, 81403 X 
2, and 81401 X 2) provided to the enrollee on December 4, 2020. 
 
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. 
The Plan says genetic testing is considered a non-covered screening test for patients unaffected by a relevant 
illness, injury, or signs/symptoms thereof. The Plan states predictive or pre-symptomatic genetic tests and 
services, in the absence of past or present illness in the beneficiary, are not covered under Medicare rules. 
 
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, the testing, 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 
full cardiology genetic panel testing assay (Hereditary Cardio screen - 117 Genes) (CPT code(s): 81408 X 2, 
81407 X 1, 81406 X 2, 81405 X 2, 81404 X 2, 81403 X 2, and 81401 X 2) provided to the enrollee on 
December 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment.
Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. 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 the services provided on December 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided on January 29, 2021.
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied
your request. The Plan says this is not documented.
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 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not document
the presence of an independent trained observer. Based on this information, we decided that Medicare rules for
coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for
sedation services (99152) provided on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on May 17, 2021.
You asked the Plan to pay for the testing services. You say that supporting medical records prove the necessity
of services. The Plan denied your request. The Plan says the documentation does not support 22 or more drug
classes.
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 G0483 is definitive drug testing of 22 or more drug
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records
provided do not indicate the testing of 22 or more drug classes was ordered based on clinical assessment, side
effects, suspicious behaviors, or symptoms of illegal drug use. Based on this information, we decided that
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does
not have to pay for the definitive drug testing provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and related accessory (E0673) provided on May 6, 2021.
You asked the Plan to pay for the durable medical equipment. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says these items are not covered by Medicare per the Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675 will be denied. The rules also say that when the related base PCD is not covered, the associated accessory will not be covered. We looked at the file and Medicare rules. In this case, the PCD coded E0675 is not covered according to Medicare rules. Since the base PCD is not covered, E0673 will be denied. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and related accessory (E0673) provided on May 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan has to reduce the cost-sharing charges for a colonoscopy. We decided that the Plan 
does not have to reduce the cost-sharing charges for a colonoscopy.  
 
You asked the Plan to reduce the cost-sharing charges for a colonoscopy. You say that this was a colonoscopy 
screening and you should not owe anything. The Plan says that the claims were processed correctly and you are 
being charged the correct amount.  
 
We decided that the Plan has to reduce the cost-sharing charges for a colonoscopy from $309.46 to $295.  
 
Your contract with the Plan says that you must pay a $295 copayment for outpatient surgery, including services 
provided at ambulatory surgical centers.  
 
The Plan says that you must pay $309.46 for a diagnostic colonoscopy. However, you cannot be asked to pay 
more than the $295 copayment for a colonoscopy provided in an ambulatory surgical center. Therefore, we 
decided that the Plan has to reduce the cost-sharing charges for a colonoscopy from $309.46 to $295.  
 
We also decided that the Plan does not have to reduce the cost-sharing charges for a colonoscopy to the 
amount you requested.  
 
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 $295 
copayment for a colonoscopy provided in an ambulatory surgical center. 
 
The medical records show that you had polyps removed during a colonoscopy provided on June 24, 2021. This 
means that the colonoscopy is considered diagnostic, not preventative. Therefore, we decided that the Plan does 
not have to waive the $295 copayment for a colonoscopy. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that you do not meet criteria for coverage. 
 
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 SNF 
care is medically reasonable and necessary. You do not have documented skilled nursing needs, though 
monitoring of your breathing, ascites and anemia is reasonable. You do have documented skilled therapy 
needs.  The documentation is insufficient to show that you are functioning at your baseline or have reached a 
new plateau in function. A period of daily skilled services is reasonable to establish a maintenance program, 
prevent deterioration of your condition and/or document a plateau in function. Our physician reviewer found 
that your condition meets Medicare criteria for SNF services. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan has to pay for the psychotherapy services (90837) received on December 8, 2020. 
 
You asked the Plan to pay for psychotherapy services. You say that the requested service was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
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. Specifically, the Plan has failed to substantiate what necessary criteria the 
provider has not met. We found that the provider is licensed in the state where the services were performed and 
is certified by Medicare. There is no compelling evidence why the provider should not receive payment for the 
services rendered. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837) 
received on December 8, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156). 
 
You asked the Plan to pre-approve home health services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says your personal care and homemaking needs are being met with an 
outside service, and HHA services duplicate personal care service. Therefore, these services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found that the 
documentation in this case does not support that you require skilled nursing services or skilled rehab services to 
provide treatment that is medically necessary. You do not require skilled nursing or rehab services to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain your condition and/or prevent deterioration. You do not require home health aide services 
as you are mostly independent, and your needs can be met with your personal care and homemaking services. 
You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide (HHA) services (G0156).