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

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you believe this code can be billed and paid 
separately. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71046. 
 
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 71046. This claim has not been billed with an appropriate modifier to 
bypass the edit. You only billed the 77 modifier on code 71045, which is not appropriate here.  As discussed in 
the rules section, the 77 modifier is not to be used for billing services that are considered bundled (as is the case 
here).  Rather, this modifier is to be used to indicate a repeat procedure. 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 71045 billed for date of service May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on January 10, 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 February 22, 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 office visit rendered on January 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99285 is bundled into payment for code 99291. 
 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 99285 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic nasal endoscopy provided on March 18, 2022, 
billed with code 31231. 
 
You asked the Plan to pay for the services as billed. You say that the records clearly support the billed services. 
The Plan denied your request. The Plan says there is no documentation of a diagnostic nasal endoscopy. 
 
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 31231 is Nasal endoscopy, diagnostic, unilateral or 
bilateral (separate procedure). 
 
We find that CPT code 31231 is not supported in the medical record. Specifically, there is no documentation 
that a diagnostic nasal endoscopy was provided that was distinct from the endoscopic services related to the 
treatment of the intranasal lesions. No separate report detailing the findings of a nasal endoscopy were 
submitted. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic nasal endoscopy 
provided on March 18, 2022, billed with code 31231.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services provided on March 10, 2021. 
 
You asked the Plan to pay for emergency department services. The Plan denied your request. The Plan says 
claim- 20220805921019500223 was received on day 512, which is beyond the 365 days, or 1 calendar year set 
forth by CMS in section 70.4 of the Medicare Claims Processing manual. Provider did not supply any proof of 
timely filing and no other prior claims found in history. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for emergency department services was not filed until August 12, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for emergency department services provided on 
March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the medically necessary services at issue were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment for OON 
care have not been met. 
 
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. The case record indicates that the referring provider is also not a network provider with 
the Plan. 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 drug testing provided on July 18, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two units of procedure code 99291 billed for date of 
service June 22, 2022. 
 
You asked the Plan to pay for the two units of procedure code 99291. You say that this should be paid as the 
service was only performed once on this date of service. 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 99291 is 1. The MAI value for this code is 2. You billed two units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the two 
units of procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
the two units of procedure code 99291 billed for date of service June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical first radiographic image provided on August 3, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this procedure was required for the proper 
diagnosis of a potential cracked tooth which could only be viewed through an x-ray. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 22, 2021. 
Therefore, we decided that the Plan does not have to pay for the periapical first radiographic image provided on 
August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (93005) provided on July 24, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria is not met. 
 
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 CPT code 93005 is not supported in the medical record. Specifically, this code has a status 
indicator of Q1. The code was billed on the same date as code 99284 which has an indicator of "V". This code 
is not separately payable from the emergency room code billed. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (93005) provided on July 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on July 14, 2022, and August 1, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you did not authorize your dental coverage to be 
terminated. The Plan denied your request. The Plan says that you had no dental coverage for these requested 
services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on 
July 14, 2022, and August 1, 2022.  
 
Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the Kansas City CMS Regional Office so that it can look into your enrollment question.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and deductible for the resin-based composite 
(D2391) for tooth #28 provided on July 7, 2022. 
 
You asked the Plan to waive the coinsurance and deductible for the dental service. You say that you would like 
the coinsurance waived. The Plan denied your request. The Plan says the proper cost share was applied for the 
dental service that was rendered. 
 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 
covered under this benefit with a coinsurance charge and once the annual deductible is met. Prior to the date of 
service, the total amount paid towards the deductible was $44. The deductible charged on the date of service 
was $6; therefore, the annual deductible of $50 was met ($44 prior paid + $6 paid). The total amount allowed 
for the dental service was $91 with a coinsurance charge of $42.50 ($91 total amount x 50% coinsurance). You 
have been asked to pay $48.50 for the resin-based composite. This item/service falls within the Dental 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 waive the coinsurance and deductible for the resin-based 
composite (D2391) for tooth #28 provided on July 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided during the emergency room 
visit on June 22, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were given a pill for nausea, which 
should be covered by the Plan. The Plan denied your request. The Plan says the self-administered drugs are not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 pay for self-administered drugs provided 
during the emergency room visit on June 22, 2022.  
 Benefits for self-administered drugs 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 a magnetic resonance image (MRI) guided high intensity 
focused ultrasound provided on October 26, 2021. 
 
You asked the Plan to pay for the MRI. You say that you are appealing the denied service. The Plan denied 
your request. The Plan says there was no scale assessing tremor and unknown prior treatment, requested 
procedure not reasonable or medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a magnetic resonance image (MRI) guided high intensity 
focused ultrasound may be covered if all of the rules of the LCD are met. 
 
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 MRI. Our reviewer says that the records 
provided for review did not readily demonstrate that the requirements of the LCD for coverage of this 
procedure were met. Our physician reviewer found There was no documentation of refractory essential tremor 
to satisfy the following requirements of medication refractory or essential tremor. The records also did not have 
any formal clinical rating scales/evaluations to meet the following requirements of moderate to severe postural 
or intention tremor of the dominant hand and disabling tremor. There were otherwise no medical 
contraindications to deep brain stimulation. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for a magnetic resonance image (MRI) guided high intensity focused ultrasound provided on October 
26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87998, 87500, 87653, 87651, 87641, 87640, 
87551, 87481, 87471) provided on June 3, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A 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. Multiple unbundled codes were submitted for a single testing panel. 
Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (87998, 87500, 87653, 87651, 87641, 
87640, 87551, 87481, 87471) provided on June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) 
provided on July 18, 2022. 
 
You asked the Plan to pay for bone replacement graft for ridge preservation (D7953). You say that your dentist 
referred you to an oral surgeon. The Plan denied your request. The Plan says according to the member's EOC, 
the member does not have coverage for bone replacement graft under the 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 bone 
replacement graft for ridge preservation (D7953) provided on July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter supplies rendered on June 15, 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 DME outside of the home is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the catheter supplies rendered on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested MyoPro is not known to 
be effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this 
enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 
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 a MyoPro orthosis.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 14, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on July 12, 2022. 
 
You asked the Plan to pay for an emergency department visit. You say that multiple exams were provided on 
this date of service. 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 services at issue were reimbursed 
by the Plan on July 28, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for an emergency department visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on  
July 12, 2022.