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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 76641. 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 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83718 and 83721 billed for date of service 
June 16, 2022. 
 
You asked the Plan to pay for procedure codes 83718 and 83721. The Plan denied your request. The Plan says 
payment for codes 83718 and 83721 is bundled into payment for code 80061. 
 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 codes 
83718 and 83721 are column II codes to column I code 80061. 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 83718 and 83721 billed for 
date of service June 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services billed to the enrollee from February 4, 2022, to March 5, 2022.
You asked the Plan to pay this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was billed incorrectly. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan shows that the provider submitted the claim with the admit date as being September 7, 2021, for the second episode of care i.e., date of service from February 04, 2022, through March 05, 2022. The first episode of care in 2022 started from January 05, 2022, through February 03, 2022. Per the listed Medicare guidelines, the provider should be submitting all the claims with the admit date as January 5, 2022, for all the subsequent claims until the patient is discharged.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was not submitted has created a billing error preventing payment based on the dates submitted for care given and their billing sequence. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for home health services billed to the enrollee from February 4, 2022, to March 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility for payment. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 13, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 11, 2021, to March 24, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate PDPM score. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided medical records do 
not document a diagnosis of morbid obesity due to excess calories signed by a physician or advanced practice 
provider. Additionally, there is no documentation that there was a cerebrovascular accident (CVA), transient 
ischemic attack (TIA), or stroke that caused cognitive impairment. The records do not contain a Brief Interview 
for Mental Status (BIMS) score of 7 signed by a physician or advanced practice provider. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from March 11, 2021, to March 
24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
March 11, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown (D2740) provided on September 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that the tooth appeared to be restorable with a dental filling. Therefore, the dental 
need for a crown has not been proven and is not covered. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says that 
the documentation provided meets the criteria for coverage for a crown restoration for tooth #21. Our physician 
reviewer found the presence of interproximal caries in tooth #21. The documentation justifies the use of a 
crown restoration by describing the extent of the caries and the difficult placement of an intracoronal 
restoration to achieve adequate function and good long term prognosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pay for the crown (D2740) provided on September 16, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous or minimally invasive bilateral sacroiliac 
(SI) joint fusion (code 27279). 
 
You asked the Plan to pre-approve percutaneous or minimally invasive bilateral sacroiliac (SI) joint fusion. 
You say that percutaneous or minimally invasive bilateral sacroiliac (SI) joint fusion is medically necessary. 
The Plan denied your request. The Plan says percutaneous or minimally invasive bilateral sacroiliac (SI) joint 
fusion does not meet the Medicare LCD coverage. criteria. 
 
The Plan follows Medicare rules. 
 
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 percutaneous or minimally invasive 
bilateral sacroiliac (SI) joint fusion. Our reviewer says that the requested percutaneous or minimally invasive 
bilateral sacroiliac (SI) joint fusion is not medically necessary. Our physician reviewer found that the enrollee 
is a 74-year-old male with a history of chronic low back pain and fibromyalgia. The records state that the 
enrollee has been having varied aching symptoms throughout his entire body; and, that this has superseded his 
normal chronic pain issues. The enrollee has had two prior SI joint injections. However, these injections resulted in only a 50% reduction of pain. The requested percutaneous or minimally invasive bilateral sacroiliac 
(SI) joint fusion does not meet the Medicare LCD coverage 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 percutaneous or minimally invasive bilateral sacroiliac (SI) joint fusion have 
not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous or minimally 
invasive bilateral sacroiliac (SI) joint fusion (CPT 27279).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 25, 2022, billed with 
codes 81225 and 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records document all services 
were provided to the enrollee. 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 
April 25, 2022, billed with codes 81225 and 81226.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on July 1, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you are disputing the share cost. 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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $110 copayment for MRI. This item/service falls within the outpatient diagnostic 
tests and therapeutic services and supplies 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 MRI provided on July 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrodesis services (procedure code 22630) provided to the 
enrollee on December 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 22630 is not supported by the medical records submitted. 
 
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 22630 is "Arthrodesis, posterior interbody technique, 
including laminectomy and/or discectomy to prepare interspace (other than for decompression), single 
interspace, lumbar." 
 
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 there is no record of interbody 
fusion in the medical records or operative note. 
 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 arthrodesis services (procedure code 22630) provided to the enrollee on December 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 11, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 is a column II code to column I code 93976. 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 76705 
billed for date of service July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 a Vertiflex device. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous device at L3-L4, in this case, is not medically reasonable or 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 17, 2022, billed 
with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, and 
81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 a panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 17, 2022, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, 81194, and 81309.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS). 
 
You asked the Plan to pre-approve BIS. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 BIS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that there is insufficient reliable evidence in the form of high quality 
peer-reviewed medical literature to establish the efficacy or effects on health care outcomes. The review has 
determined that  the items/services at issue in this case are not medically reasonable or 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 BIS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve bioimpedance spectroscopy (BIS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for an LTACH 
admission. The Plan denied your request. The Plan says that admission to LTACH was denied as not meeting 
criteria, not medically necessary 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care 
setting. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the Plan. The Plan has approved ongoing care in the current acute care 
setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided on May 14, 
2022. 
 
You asked the Plan to pay for the electrical stimulator. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The proof of delivery is not itemized and there is no 
order number. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies 
(A4595) provided on May 14, 2022.