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

 
We decided that the Plan does not have to pay for the telehealth services provided on February 10, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that you would like this claim reprocessed based 
on medical necessity. The Plan denied your request. The Plan says although OON services are available, the 
Plan's contract specifies that telehealth services will only be covered in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan will never cover telehealth services when they are rendered by an OON provider. 
 
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 the telehealth services provided on February 10, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services (pacemaker) provided to the 
enrollee on July 22, 2020. 
 
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 procedure note and implant summary does not indicate that a second pacemaker was 
implanted, contaminated, or discarded. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 services. Our reviewer says that the second pacemaker is not supported in the medical records. Our physician reviewer 
found a medical record review reveals that the patient's single-chamber ICD was upgraded to a CRT-D system, 
with placement of a right atrial lead, a left ventricular lead, removal of the old generator, and insertion of a new 
Medtronic Claria CRT-D generator, serial number RPS206397H. There is no documentation of the disposition 
of a second CRT-D generator for which billing was submitted. In summary, the records do not show evidence 
of implantation, contamination, or disposal of a second CRT-D generator. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services (pacemaker) provided to the enrollee on July 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second chest x-ray received on August 20, 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 there is no documentation supporting an additional study, which was billed and remains denied. 
 
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 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 records show one chest x-ray - 
CPT 71045 - done on 8/20/21, and exposed at 9:50, and signed by the doctor at 10:18. A second exam on the 
same date is not documented in the records submitted. 
 
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 a second chest x-ray received on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitored anesthesia care provided on September 11, 2020. 
 
You asked the Plan to pay for the monitored anesthesia care. You say that these services were billed correctly. 
The Plan denied your request. The Plan says you billed with an incorrect place of service (POS) on the claim.  
The records show that the patient was an inpatient on the date of service in question. 
 
The Plan must follow Medicare rules. Medicare rules say that for services rendered to a hospital patient, the 
correct outpatient (22) or inpatient (21) POS code should be used. In this case, you billed with POS 22, which 
would indicate that the patient was an outpatient in the hospital.  However, records show that the patient was a 
hospital inpatient on the date of service in question, so the correct POS should have been 21. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the monitored anesthesia care have not been met. Specifically, this claim was billed with an incorrect POS code. Therefore, we decided that the Plan does not have to pay for monitored anesthesia care 
provided on September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry, per 
specimen; initial single antibody stain procedure (88342) surgical pathology, gross and microscopic 
examination (88305) provided December 21, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that this was a resubmission of the claim which 
was originally denied for provider not being eligible. Please review and reprocess this claim for payment. The 
Plan denied your request. The Plan says while you can get your care form an out of network provider, the 
provider must be eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure (88342) 
surgical pathology, gross and microscopic examination (88305) provided December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure (81479) BRCA1, BRCA2 
(breast cancer 1 and 2) (81162) provided June 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee clearly meets 2021 criteria for 
genetic testing published by the National comprehensive cancer Network. The Plan denied your request. The 
Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those 
two or more genes will be considered part of the same panel. 
 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 Myriad myRisk(tm) Hereditary Cancer testing has not undergone to process of approval and 
evaluation through MoIDX. 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 the 
molecular pathology procedure (81479) BRCA1, BRCA2 (breast cancer 1 and 2) (81162) provided June 30, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the emergency room services provided on 
October 7, 2021. 
 
You asked the Plan to waive the cost share for the emergency room services. You say that you would like this 
claim reprocessed. The Plan denied your request. The Plan says the copayment has processed correctly for the 
services received. 
 
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 $90 
copayment for Emergency care.  
 
You have been asked to pay a $90 copayment for the emergency room services. This care falls within the emergency care 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 cost share for the emergency room 
services provided on October 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50-mile one way limit for routine 
transportation. 
 
You asked the Plan to pre-approve this exception. You say that this exception is necessary for you to see a 
provider. The Plan denied your request. The Plan says exceptions are not made to the transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. The Plan offers a transportation benefit 
that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan does not 
cover routine transportation beyond 50 miles one way. Neither Medicare nor Maximus can make exceptions to 
supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50-
mile one way limit for routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on June 30, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on medical necessity. The Plan denied your request. The Plan says this testing service has not been 
shown to be useful and is not considered medically necessary and appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on June 30, 2021, have been met. In this case, medical records were not received from the ordering physician demonstrating the medical necessity of the requested procedure. Therefore, we decided that the Plan does not 
have to pay for the genetic testing services provided on June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hepatitis B vaccine. 
 
You asked the Plan to pre-approve the hepatitis B vaccine. The Plan denied your request. The Plan says The 
Plan says that the denial of payment for this service is correct. The Plan also says that coverage has been 
approved under the enrollee's Medicare Part D benefit. 
 
Medicare only provide the hepatitis B vaccine under Part B benefits when a beneficiary is at high or 
intermediate risk of contracting Hepatitis B. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the hepatitis B 
vaccine or that you are high or intermediate risk of contracting Hepatitis B. Therefore, we decided that the Plan 
does not have to pre-approve the hepatitis B vaccine.  
 
Benefits for the hepatitis B vaccine have been approved under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for plastic surgery (procedure code 15275) provided to the 
enrollee on September 16, 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 code 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 15275 is "Application of skin substitute graft to face, 
scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area 
up to 100 sq cm; first 25 sq cm or less wound surface area." 
 
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 documentation describes "wound 
fix" , which cannot be verified as a skin substitute graft. Per the guidelines, non-graft wound dressings would 
be inclusive to wound care.  
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 plastic surgery (procedure code 15275) provided to the enrollee on September 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission to be 
provided by a network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF admission. You say that it is unsafe to return home alone and 
without help. The Plan denied your request. The Plan says authorization because the SNF admission is not 
medically necessary and your needs can be met at a lower level of care such as home with home health, in 
residential care, or home with close follow-up with your doctor and caregiver assistance. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records, there 
is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. The records do not document the need for intravenous medications, new tube 
feeding, or ostomy care or daily complex wound care. Based on the medical records provided you do require 
skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required 
to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records 
provided, there is no documentation that daily skilled services are required. You are walking household 
distances with a rolling walker with contact guard assistance and is contact guard assist for transfers. The 
provided records do not document a significant decline in your functional status to necessitate daily inpatient 
skilled therapy services. Based on the medical records provided there is no documentation that you require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health 
care or in a long-term care facility on a part time basis appear 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the skilled nursing facility (SNF) admission to be provided by a network facility.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography (93313) provided on May 27, 2021. 
 
You asked the Plan to pay for the echocardiography. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 93313 and 
00560.  
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 93313 
is a column II code to column I code 00560. 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 echocardiography (93313) provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option. 
 
You asked the Plan to pre-approve a manual wheelchair to include a transit option. You say that the wheelchair 
and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says while the 
wheelchair and Medicare allowed accessories were approved, the transit option is not covered by Medicare. 
The Plan notes that the enrollee is dual eligible and the requested for the transit option should be requested 
under the enrollees Medicaid benefit.  
 
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. This transit option 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 pre-approve an ultralight manual wheelchair and accessories to include a transit 
option. It should be noted the Plan has stated the transit option might possibly be covered under the enrollees 
Medicaid benefit. The IRE does not have jurisdiction over Medicaid benefits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approved additional routine transportation. 
 
You asked the Plan to pre-approved additional routine transportation. You say that the enrollee requires 
additional transportation because they attend outpatient pulmonary rehabilitation. The Plan denied your 
request. The Plan says the enrollee is only covered for 10 trips per year, regardless of the reason.  Additional 
trips cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approved additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet step therapy exception 
criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative, 
zoledronic acid. Our physician reviewer found the record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mastectomy services (procedure code 19303) provided to the 
enrollee on July 1, 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 this was not billed correctly for a bilateral procedure. 
 
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 19303 is "Mastectomy, simple, complete." 
 
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 a bilateral mastectomy was 
performed; however, the services were billed incorrectly. In this case, modifier 50 should be appended for the 
bilateral service with one unit.  
 
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 mastectomy services (procedure code 19303) provided to the enrollee on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that a manual wheelchair is medically 
necessary for the enrollee. The Plan denied your request. The Plan says Medicare does not cover durable 
medical equipment for use in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The records 
show that a manual wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a manual wheelchair for the enrollee.