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

 
We decided that the Plan does not have to pay for the lab services provided on September 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that 3 pathogens of code 87481 should be paid. The 
Plan denied your request. The Plan says the codes remain 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. 
 
We find that code 87640 was billed with the -59 modifier. The medical records provided do not show that the 
service billed with the -59 modifier was a distinct procedural service. We find that 5 units of code 87481 was 
not supported in the medical records. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 64450. You say that this service was billed correctly. The Plan 
denied your request. The Plan says the payment for code 64450 is included in the payment for code 00210. 
Although code 64450 was billed with a modifier, the records do not support that this modifier was used 
appropriately. 
 
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 64450 
is a column II code to column I code 00210; however, 64450 was billed with a modifier.  
 
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 procedure code 64450. Our reviewer says that the medical 
records do not support separate billing of code 64450. Our reviewer found this service would be included 
within the surgery and anesthesia provided to the patient on the same day. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64450 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64450 billed for date of service August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the principal care management services provided on October 
20, 2022. 
 
You asked the Plan to pay for the principal care management services. You say that the enrollee was in a 
nursing home and could not choose a specific provider. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the principal care 
management services provided on October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140)
provided on May 24, 2022.
You asked the Plan to pay for the limited oral evaluation-problem focused. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this is not
covered unless provided by an oral surgeon.
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. The Plan covers the limited
oral evaluation-problem focused when performed by an oral surgeon. We looked the file and Plan rules. The
performing provider is not an oral surgeon. Based on this information, we decided that the Plan's rules for
coverage of the limited oral evaluation-problem focused have not been met. Therefore, we decided that the
Plan does not have to pay for the limited oral evaluation-problem focused (D0140) provided on May 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Actemra IV for the enrollee.
You asked the Plan to provide coverage for Actemra IV. You say that you requested Actemra IV for the
enrollee as it is less expensive than the subcutaneous form. In addition, you noted there was a shortage in
subcutaneous Actemra. The Plan denied your request. The Plan says based on the medical records
subcutaneous Actemra is the only approved application for the enrollee's condition. In addition, due to the 20%
coinsurance, there would most likely be a greater cost for the IV infusion. The Plan confirmed the shortage of
the subcutaneous pens was resolved at the time of the appeal and the enrollee's pharmacy confirmed they had it
in stock. Maximus overturned the Plans denial stating the drug was medically necessary. The Plan requested a
reopen and stated that Maximus did not apply the correct decision criteria.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. The Plan is correct in that the cost for Actemra IV, had a 20% coinsurance that could
be applied to both the drug itself and any administration fees. Cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. If the enrollee is having financial hardship with prescriptions,
they should contact the Plan for any available programs that can help in their area. Also, the internet also lists
several websites enrollees can contact for assistance with the cost of Actemra. Therefore, we decided that the
Plan does not have to provide coverage for Actemra IV for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal x-rays provided on September 05, 2022. 
 
You asked the Plan to pay for the abdominal x-rays. You say that the enrollee was in a nursing home and 
authorization should be included with their admission. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the abdominal x-rays 
provided on September 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 16, 2022, billed 
with codes 87150, 87798, 87481, 87801, 87640, and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that your lab performed all of the tests that 
were ordered by the referring physician. Please review and reprocess the above claim following the CMS 
guidance. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
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 
November 16, 2022, billed with codes 87150, 87798, 87481, 87801, 87640, and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, and 87641 
billed for date of service November 10, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798, and 87641. You say that this 
should be paid as billed due to medical necessity. The Plan denied your request. The Plan says payment for 
codes 87150, 87481, 87653, 87798, and 87641 is bundled into payment for codes 87801 and 87500. 
 
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 87150, 
87481, 87653, 87798, and 87641 is a column II code to column I code 87801 and 87500. 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 codes 
87150, 87481, 87653, 87798, and 87641 billed for date of service November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95940, 95861, 95937, 95955 and G0453 
billed for date of service August 31, 2022. 
 
You asked the Plan to pay for procedure codes 95940, 95861, 95937, 95955 and G0453. You say that the 
services at issue have been billed correctly. The Plan denied your request. The Plan says the provided records 
do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 95940 is: Continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List 
separately in addition to code for primary procedure). 
 
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 procedure code 95940. Our reviewer says that procedure 
code 95940 does not meet criteria for payment. Our reviewer found that the available documentation states that 
remote monitoring was performed. However, procedure code 95940 requires one-on-one monitoring with 
personal attendance. There is a more specific code for remote intraoperative monitoring. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95940 have not been met. Additionally, we have confirmed that 
codes 95861, 95937, 95955 and G0453 are column II codes to column I code 51785. These claim lines have 
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 codes 
95940, 95861, 95937, 95955 and G0453 billed for date of service August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 80076 and 85007 
for August 24, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the laboratory services billed with codes 80076 and 85007 for 
August 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on August 02, 2022, to 
September 20, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy visit 
provided on August 02, 2022, to September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on September 29, 2022. 
 
You asked the Plan to pay for mental health services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for mental health services 
provided on September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), a standard remote joystick (E2374), 
an expandable controller (E2377) and a transit package (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee's needs. The Plan denied your request. The Plan says the joystick 
replacement is not to be given in a new wheelchair request. The upgraded electronics are not medically 
necessary. The transit package does not primarily serve a medical purpose. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided records document that the enrollee has 3+/5 to 4-/5 upper extremity strength 
and is supervision for eating thus indicating she has adequate upper extremity strength and function to operate 
the wheelchair's power options with their own switches. The requested transit package is statutorily non-
covered as it serves no primary medical purpose. The available medical records do not support necessity of the 
equipment as defined by Medicare criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), a standard remote joystick (E2374), an expandable 
controller (E2377) and a transit package (K0108).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on May 12, 2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that more than 
22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0483 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0483 provided on May 12, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740), gingival irrigation (D4921) and unspecified periodontal procedures (D4999) provided from June 2, 2022, through June 14, 2022.

You asked the Plan to pay for the porcelain/ceramic crowns, gingival irrigation and unspecified periodontal procedures. You say that payment was denied for all three appointments required to evaluate the need for, prepare for and apply the crowns. The Plan denied your request. The Plan says that the dental services received are not covered benefits.

The porcelain/ceramic crowns (D2740) received were for molar teeth. The Evidence of Coverage clearly states
that only base metal materials are covered for crowns on molar teeth. In addition, gingival irrigation (D4921)
and unspecified periodontal procedures (D4999) are not listed as a covered routine or optional dental benefit. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740), gingival irrigation (D4921) and unspecified periodontal procedures (D4999) provided from June 2, 2022, through June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 02, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
November 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on November 
19, 2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that your regular doctor was 
unavailable so the practice told you that you can go to a walk up clinic. 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 $30 
copayment for urgently needed services. 
 
You have been asked to pay a $30 copayment for an urgent care visit. This item/service falls within the 
urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for an urgent 
care visit provided on November 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 22, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
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 $125 
copayment for outpatient diagnostic tests/ultrasound. 
 
You have been asked to pay a $125 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/ultrasound benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
ultrasound provided on September 22, 2022.