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

 
We decided that the Plan does not have to pay for lab services provided on April 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Units) remains 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 4, 2022.
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 you are in and out of the hospital and need to have 
rehabilitation at a SNF. The Plan denied your request. The Plan says criteria for admission to SNF have not 
been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on December 16, 2021. 
 
You asked the Plan to pay for the annual wellness visit. You say that this was your normal 6 month follow-up 
visit and the claim was coded incorrectly. The Plan denied your request. The Plan says you previously had 
wellness billed on December 14, 2021. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on 
December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation, per quadrant (D4921). 
 
You asked the Plan to pre-approve dental services. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or the Plan. 
 
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 pre-approve 
gingival irrigation, per quadrant (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have COPD and were recently 
hospitalized. ABG was consistent with mild acute on chronic hypercarbic respiratory failure. However, there is 
no documentation of chronic CO2 retention with ABG while stable. If you do have chronic CO2 retention, you 
may benefit from BiPAP with AVAPS during sleep.  But Medicare does not cover a home ventilator when used 
as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies and materials provided by the physician or other 
qualified health care professional from May 4, 2022, to June 29, 2022. 
 
You asked the Plan to pay for supplies and materials provided by the physician or other qualified health care 
professional. The Plan denied your request. The Plan says the provider is not a Medicare qualified mental 
health care professional. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) and a 
Licensed Professional Counselor are not eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT) and a Licensed Professional Counselor. Medicare says that a Marriage Family Therapist (MFT) and a 
Licensed Professional Counselor are not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for supplies and materials provided by the physician or other qualified health 
care professional from May 4, 2022, to June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from July 1, 2022, to July 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim was 
billed incorrectly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the services provided from July 1, 2022, to July 
11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on May 9, 2022, to 
May 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that code 99232 was billed and paid by the Plan on 
the same date of service by a physician of the same specialty in the same group practice. 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 pay for the subsequent hospital care rendered on May 9, 2022, to May 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 19, 2021, billed 
with codes 81206, 81301, 81292, 81295, 81298, 81317, 81321, 81162, 81191 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that this panel was medically necessary and is 
supported in the medical record. 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 
December 19, 2021, billed with codes 81206, 81301, 81292, 81295, 81298, 81317, 81321, 81162, 81191 and 
81401.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for wound care provided on  
March 2, 2022. 
 
You asked the Plan to pay for physician's services for wound care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 
providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services for wound care provided on March 2, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from November 2, 2021, to November 
19, 2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that the Request for Anticipated Payment 
(RAP) pertaining to this period of care reports a range of date when instead the "from" and "through" dates 
must be the same. We find this is not a reasonable interpretation of the rules. It is the Plan's responsibility to 
substantiate its denial. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for home health services provided from November 2, 2021, to 
November 19, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Zilretta. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has bilateral knee pain and a diagnosis of bilateral osteoarthritis of the knees who 
last received a Zilretta injection for each knee on October 3, 2022. As stated in drug manufacturer's prescribing 
information, the efficacy and safety of repeat administration of Zilretta have not been demonstrated. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service July 13, 
2021. 
 You asked the Plan to pay for procedure code 74176. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
code 74178. 
 
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 74176 
is a column II code to column I code 74178. 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 74176 billed for date of service July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint block and aspiration of seroma 
(27096, J1040, J1100, J3490, 72200, 77003) to be provided by an out-of-network neurosurgeon. 
 
You asked the Plan to pre-approve the network exception. You say that your primary care physician referred 
you to this doctor. You say that you are comfortable with their diagnosis. You also say that this doctor is aware 
of your 3 failed back fusions and believes he can correct them. The Plan denied your request. The Plan says 
there are in network providers available. The Plan also says if after an evaluation with an in-network provider, 
the provider feels that the out-of-network provider is necessary, then the out-of-network provider can be 
approved at that time. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 network exception. Our reviewer 
says that the requested network exception for these services is not medically necessary. Our physician reviewer 
found the record provided does not indicate that network providers are unavailable or inadequate to meet an 
enrollee's medical needs. The reviewer found that the plan has identified a network provider who is available 
and can provide the needed services. Therefore, the reviewer found that the requested network exception is not 
medically necessary at this time. 
 
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 network exception have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint block and aspiration of seroma (27096, J1040, J1100, 
J3490, 72200, 77003) to be provided by an out-of-network neurosurgeon.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve electron radiotherapy treatment. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the request for this treatment cannot be approved by Medicare or the health 
plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 treatment. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that this patients cancer is described as being 2 cm in size. The tibia would not be cosmetically sensitive 
or poorly vascularized or cartilaginous. 22 fractions of electron beam radiation would fall within the National 
Comprehensive Care Network (NCCN) guidelines. Protracted fractionation is associated with improved 
cosmetic results and should be utilized for poorly vascularized or cartilaginous areas. 
 
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 treatment have been met. Therefore, we decided that the Plan has to pre-
approve electron radiotherapy treatment.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
20, 2022, to May 24, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG and secondary diagnosis is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 175. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that based on the above documentation, the records do not support the use of secondary diagnosis code J96.01 
(acute respiratory failure with hypoxia) in this case. Also, the records do not support the DRG 175 
(PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE) as the presentation was of 
lower severity and did not involve acute respiratory failure. A more appropriate DRG would be 176 
(PULMONARY EMBOLISM WITHOUT MCC) in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 20, 2022, to May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $40 copayment charged for podiatry services
provided on January 5, 2022.
You asked the Plan to waive or reduce this cost share. You say that you think the copayment should be $30.
The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
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 $40 copayment for podiatry services. The medical records show these were
podiatry services.
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 or reduce the $40 copayment charged for podiatry services provided on January 5, 2022.