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

 
We decided that the Plan does not have to pay for Office Visit services provided on December 20, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Office Visit services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Office Visit services provided on December 20, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on 
October 5, 2021. 
 
You asked the Plan to pay for the monitor. You say that there are medical records and proof of delivery to 
support this item. The Plan denied your request. The Plan says there was no information pertaining to how 
often the patient administers insulin. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.  
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 monitor. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
records do not show that the enrollee has been using a blood glucose monitor, and performing testing four or 
more times per day. The enrollee is not insulin-treated with three or more daily injections of insulin. The 
insulin treatment regimen does not require frequent adjustment on the basis of test results. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pay for a continuous glucose monitor provided to the enrollee on October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on June 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 22845: 
 
Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) 
 
CPT 63265: 
 
Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical 
 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 in terms of CPT 22845, the 
operative report does not include documentation of a separate plate spanning the interspace for independent 
stabilization. Therefore, CPT 22845 would be inclusive to CPT 22853. In terms of CPT 63265, the operative 
report does not include documentation of a laminectomy for excision or evacuation of intraspinal lesion. 
 
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 surgical services provided to the enrollee on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound management services (Q4118) provided to the 
enrollee on May 12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code Q4118 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 Q4118 is "Matristem micromatrix, 1 mg." 
 
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 the procedure report does not continue 
documentation of the billed and denied code. 
 
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 wound management services (Q4118) provided to the enrollee on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network prosthetic services for the enrollee.
You asked the Plan to pay for out of network providers. You say that the requested provider is closer to the
enrollee's home. The Plan denied your request. The Plan says this prosthetic equipment can be provided in
network. Maximus overturned the Plans denial stating a list of in network providers had not been submitted.
The Plan requested a reopen and provided a list of providers in network who could serve the enrollees
prosthetic needs.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only
in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a
network provider with the Plan.
The Plan has submitted a list of providers who can render prosthetics and services to the enrollee. Therefore,
we decided that the Plan does not have to pay for out of network prosthetic services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pigmented lesion assay (0089U-XS-x2) provided May 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached clinical 
documentation that support the medical necessity for services. The Plan denied your request. The Plan says 
documents do not support medical necessity of a PLA to be performed to 2 other separate lesions 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clinical documentation provided supporting medical necessity of a PLA to 
be performed to 2 other separate lesions. The LCD states: Only one test may be used per patient per clinical 
encounter in most cases. In roughly 10% of patients a second test may be indicated for the same clinical 
encounter. For rare cases where more than 2 tests are indicated in a single clinical encounter, an appeal with 
supporting documentation may be submitted for additional tests. The medical records provided did not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for pigmented lesion assay (0089U-XS-x2) provided May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87324 
is a column II code to column I code 87507. 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 laboratory services rendered on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a two-wheeled walker with contact guard assistance and is stand-by assist for 
transfers. Provided records do not document a significant decline in your functional status to necessitate daily 
inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Records do not document that services in the home with home health care or in a long-
term care facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 28, 2021, billed with two 
units of code 81479-XU. 
 
You asked the Plan to pay for the testing as billed. You say that this was billed correctly and should be paid due 
to medical necessity. The Plan denied your request. The Plan says genetic panels must be billed with a single 
code for the entire test. Therefore, only 3 of the 5 billed codes have been approved for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing 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. We find that this was an NGS panel which needs to be billed as a 
single panel code. Based on this information, we decided that Medicare rules for coverage of the testing as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on July 28, 2021, billed with two units of code 81479-XU.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to waive copayment charged for lab services provided on August 24, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the service provided and the Plan
contract agreement. Maximus overturned the Plans denial because the case file lacked a plan contract for
review. The Plan requested a reopen and provided the required contract.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $10 copayment for each lab service per day. 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 copayment
charged for lab services provided on August 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance provided on August 25, 2021, billed 
with code 76937. 
 
You asked the Plan to pay for the ultrasound guidance. You say that this should be paid. The Plan denied your 
request. The Plan says this was not billed with a required modifier.  
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 76937 
is a column II code to column I code 93971. 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 ultrasound guidance provided on August 25, 2021, billed 
with code 76937.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness for an 
upgrade to an expandable controller (E2313), an electronic connection between wheelchair controller and 2 or 
more power seating system motors (E2311) and a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says the requested items do not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair accessories. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation that the requested power wheelchair accessories meet Medicare criteria for coverage. Provided 
records document that the enrollee has "good motor strength in the right upper extremity" thus indicating he 
has adequate upper extremity strength to operate the wheelchairs power options with their own switches. The 
power seat elevation system is statutorily non-covered as it does not serve a primary medical purpose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377), a harness for an upgrade to an expandable 
controller (E2313), an electronic connection between wheelchair controller and 2 or more power seating system 
motors (E2311) and a power seat elevation system (E2300).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services and rhythm electrocardiogram (ECG) 
report rendered on August 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of these services have not been 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. In this case, we have confirmed that code 93042 
is a column II code to column I code 99152. 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 medical services and rhythm 
electrocardiogram (ECG) report rendered on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 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 must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 16, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were told at the payment desk 
that there was no charge because it was a follow-up visit after being seen in the emergency room on December 
10, 2021. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 $35 
copayment for each Medicare-covered specialist visit.  
 
 
 
 
 
 You have been asked to pay a $35 copayment for each Medicare-covered specialist visit for an office visit. an 
office visit falls within the physician/practitioner services, including doctors office visits 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 office visit provided on December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted special service, procedure or report (CPT code 
99199) and the oxygen concentrator (CPT code E1390) purchased on March 29, 2021, from a non-certified 
Medicare provider. 
 
You asked the Plan to pay for the DME. You say that the doctor is giving a written statement that you need this 
equipment for your health and wellbeing. The Plan denied your request. The Plan says this provider is not 
under contract with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. This provider is not a Medicare 
enrolled provider, and as such is not eligible for reimbursement from Medicare for services rendered, as well as 
this item was purchased not rented. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pay for unlisted special 
service, procedure or report (CPT code 99199) and the oxygen concentrator (CPT code E1390) purchased on 
March 29, 2021, from a non-certified Medicare provider.