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

 
We decided that the Plan has to pay for the office visit received on May 5, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the services were billed with an incorrect place of service. 
 
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. Review of the file shows that the Plan states that the claim was billed with an 
incorrect place of service. However, no medical records were provided with the case file to Maximus. This 
means no documentation was provided to support where the place of service was provided. No other denial 
rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to 
pay for the office visit received on May 5, 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve the skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that  The Plan denied your 
request. The Plan says that  
 
The Plan agreed to pre-approve the skilled nursing facility services. Therefore, there is no need for a coverage 
decision. 
 Therefore, we decided that the Plan has to pre-approve the skilled nursing facility services.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the nursing home will not be able to provide the 
level of care needed for rehabilitation. You want to be able to walk, care for herself unassisted, you have 
difficulty keeping balance and needs continued physical and occupational therapy. The Plan denied your 
request. The Plan says your records do not show that your rehab needs are complex, your medical conditions 
are all stable, services you need can be provided safely in other settings, a skilled nursing facility, home with 
home health services or home with outpatient therapy. 
 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 your documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 86077. You say that the pathology reports the services billed. 
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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0006). 
 
You asked the Plan to pre-approve a heavy-duty manual wheelchair. You say that you say that your current 
wheelchair is in the basement and when you go upstairs by stair lift, you need a manual wheelchair to get to the 
kitchen or get in and out of the house. The Plan denied your request. The Plan says you did not meet criteria for 
approval of the requested wheelchair because payment is made for only one wheelchair at a time. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you were approved for a lightweight wheelchair on September 13, 2017. The lightweight 
wheelchair serves the same purpose as a heavy-duty manual wheelchair. Medicare rules show that payment is 
made for one wheelchair at a time, therefore, back up chairs are denied. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty manual wheelchair (K0006).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left obturator and femoral accessory neuroablation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee is being treated for 
unilateral primary osteoarthritis of the left hip. Multiple plausible pain generators are present. Moreover, there 
is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the noted pathology. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested left obturator and femoral accessory neuroablation 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left obturator and femoral accessory neuroablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator (PNS) device 
(64555 and L8679). 
 
You asked the Plan to pre-approve an auricular PNS device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is considered experimental. 
 
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 an auricular PNS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an auricular PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an auricular peripheral nerve stimulator (PNS) device (64555 and L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power feature 
and accessories (E0953, E0955, E1002, E1012, E1028, E2311, E2361, E2607, E2620, K0108, K0856, E1012). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with a single power feature and accessories. 
You say that this wheelchair is medically necessary. The Plan denied your request. The Plan says coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that to qualify for a group 3 power wheelchair with single 
power option, there must be medical need for a special drive control (including, but not limited to, head 
control, sip and puff, switch control) or for single power option: power tilt or power recline. 
 
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 group 3 power wheelchair with a 
single power feature and accessories. Our reviewer says that the requested wheelchair is not medically 
necessary. Our physician reviewer found the clinical documentation does not show why a lower-level or group 
2 power wheelchair would not suffice for the enrollee's needs versus a group 3 power wheelchair. He is noted 
to be at risk for skin breakdown and unable to adequately perform pressure relief, but there is inadequate 
clinical documentation regarding why he requires both power tilt and recline and why a group 2 power wheelchair with power tilt would not suffice. Since coverage criteria has not been met for the base wheelchair, 
the accessories are also non-covered. 
 
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 group 3 power wheelchair with a single power feature and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair 
with a single power feature and accessories (E0953, E0955, E1002, E1012, E1028, E2311, E2361, E2607, 
E2620, K0108, K0856, E1012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 3, 2022, billed 
with codes 81227, 81231, 81232, 81291, 81306, 81328, 81335, 81225, 81226, 81240, 81241, 81479 and 81238. 
 You asked the Plan to pay for the genetic testing billed. You say that this testing was 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 
September 3, 2022, billed with codes 81227, 81231, 81232, 81291, 81306, 81328, 81335, 81225, 81226, 
81240, 81241, 81479 and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and lab testing services provided on 
November 23, 2022. 
 
You asked the Plan to pay for the services provided by. The Plan denied your request. The Plan says the 
diagnosis code is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that the services at issue were billed with primary diagnosis code Z82.61, family history of arthritis. 
The reason for the encounter should be sequenced first. Based on this information, we decided that Medicare 
rules for coverage of the services provided by have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit and lab testing services provided on November 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from February 7, 2022, to March 
5, 2022. 
 
You asked the Plan to pay for home health care. You say that you did not receive the needed information in 
time for a timely Notice of Admission (NOA). The Plan denied your request. The Plan says this claim was not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for beneficiaries received home health care in 
2021 whose services will continue in 2022, the home health agency (HHA) shall submit a Notice of Admission 
(NOA) with a one-time, artificial admission date corresponding to the From date for the first period of 
continuing care in 2022.  
 
We looked at the file and Medicare rules. The From date on this claim does not correspond to the first period 
of continuing care in 2022 in accordance with Medicare billing rules. Based on this information, we decided 
that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan 
does not have to pay for home health care provided from February 7, 2022, to March 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing you received from November 7, 2022, 
to December 6, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the COVID-
19 testing you received from November 7, 2022, to December 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lipid profile (80061) provided on September 13, 2022. 
 
You asked the Plan to pay for the lipid profile. You say that you have this test every year and it has always 
been covered after appeal. The Plan denied your request. The Plan says that this claim is denied. 
 
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 has provided no specific reason for denial in this case, nor 
has the Plan supported their denial with evidence and a relevant citation. The Plan's denial is not substantiated 
in this case. Therefore, we decided that the Plan has to pay for the lipid profile (80061) provided on September 
13, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the neck brace (L0180) provided on November 17, 2022. 
 
You asked the Plan to pay for the neck brace. The Plan denied your request. The Plan says that the 
documentation submitted did not sufficiently support the billed supply code. 
 
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. The Plan argues that the documentation submitted did not sufficiently support 
the billed supply code. However, the records contain a written order for the neck brace, as well as an itemized 
shipment receipt dated November 17, 2022, with the same tracking number as the delivery ticket dated 
November 19, 2022. As such, the records support that the item at issue in this case was ordered and delivered. 
Therefore, we decided that the Plan has to pay for the neck brace (L0180) provided on November 17, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, non-emergency transport provided on 
September 23, 2022 
 
You asked the Plan to pay for the ambulance service. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says the ambulance transport was not 
medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance service. Our reviewer says 
that the ambulance transport was not medically necessary. Our physician reviewer found the transportation via 
ambulance to an imaging appointment was not medically necessary. The enrollee did not require the expertise 
of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport.  
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition.  
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 ambulance service have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, non-emergency transport provided on September 23, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neuromuscular stimulator (E0745) provided October 
21, 2022. 
 You asked the Plan to pre-approve the neuromuscular stimulator. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan 
denied your request. The Plan says neuromuscular electrical stimulation is not covered for the documented 
diagnose 
 
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 the neuromuscular stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a muscle strain of the lower back area. However, the 
provided records did not describe a covered indication for use of this device such as diffuse muscle atrophy 
from brain or spinal cord injury or peripheral nerve injury for which there is evidence to support the use of 
NMES. Therefore, this request for the neuromuscular stimulator will be considered not medically 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 the neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the neuromuscular stimulator (E0745) provided October 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided to the enrollee on November 16, 
2022. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that physical 
exams and other services required by third parties such as obtaining or maintaining employment or 
participation in employee programs, required for insurance or licensing, requested sports physicals, or on court order or required for parole or probation are not covered under any condition. 
 
Review of the file show that the enrollee was provided a chest x-ray on November 16, 2022. This x-ray was 
provided as a requirement for admission to a residential institution. Services provided as a third-party 
requirement are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay 
for the chest x-ray provided to the enrollee on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service July 16, 
2022. 
 
You asked the Plan to pay for procedure code S9500. You say that the claim was short paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service July 16, 2022.