Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve testis removal (54530). 
 
You asked the Plan to pre-approve testis removal. You say that you are in constant pain. The Plan denied your 
request. The Plan says that this is not necessary for your condition. 
 
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 testis removal. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the records show that you have chronic bilateral orchialgia and have failed conservative management. 
Orchiectomy is appropriate and indicated under these circumstances.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of testis removal have been met. Therefore, we decided that the Plan has to pre-
approve testis removal (54530).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service February 1, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641.  
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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service February 1, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2022, billed with 
codes 87798, 87481, 87561, 87640, 87651, and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 20, 2022, billed with codes 87798, 87481, 87561, 87640, 87651, and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on October 12, 
2021. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the testing is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service. A respiratory pathogen panel test must not be unbundled and billed as 
individual components regardless of the fact that the panel reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. The requested respiratory pathogen panel was not billed with a single 
unit of service as required by LCA A58577. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory pathogen panel provided on October 12, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve unlisted procedure, endocrine system (radiofrequency ablation of 
the thyroid (a treatment that uses heat to shrink nodules (a growth of abnormal tissues)) (CPT code 60699). 
 
You asked the Plan to pre-approve the services. You say that you have three (3) nodules growing by clavicle 
and if you do not get surgery soon, it could become a more serious chest surgery. The Plan denied your request. 
The Plan says that the service is not medically necessary. 
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this is a reasonable treatment plan in you, who are not interested in surgery and are advised to 
pursue treatment of this nodule. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve unlisted procedure, endocrine system (radiofrequency ablation of the thyroid (a treatment that uses 
heat to shrink nodules (a growth of abnormal tissues)) (CPT code 60699).  
 
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 lab services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on March 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve onabotulinumtoxin injection (CPT code J0585 X 400), 
chemodenervation of one extremity; 5 or more muscles (64644 X 4) and needle electromyography for guidance 
in conjunction with chemodenervation (95874 X 4). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee does not meet for non-preferred as they had not been tried on the preferred medication either Xeomin or Dysport. The Plan states the enrollee has not had the non-preferred 
medication within the last 365 days. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Xeomin and Dysport before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the Plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve onabotulinumtoxin injection (CPT code J0585 X 400), chemodenervation of one 
extremity; 5 or more muscles (64644 X 4) and needle electromyography for guidance in conjunction with 
chemodenervation (95874 X 4).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services on April 17, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you would like to appeal the 
cost share. 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 a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance services 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 ambulance services 
on April 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for Covid testing (U0004, 
U0005) provided on January 7, 2022. 
 
You asked the Plan to reimburse you an additional amount for Covid testing. You say that the insurance must 
reimburse the non-contracted provider in an amount that equals the cash price for such services listed by the 
provider on a public internet website. You are requesting the claim to be reprocessed to pay a total of $250.00. 
The Plan denied your request. The Plan says you must accept Medicare rates for the COVID test. CMS rule 
dictates providers that participate with Medicare must accept the Medicare reimbursement as payment in full. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Covid testing have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to reimburse you an additional amount for 
Covid testing (U0004, U0005) provided on January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cranial electrotherapy stimulation (ces) system, includes 
all supplies and accessories, any type (K1002) provided December 22, 2021. 
 
You asked the Plan to pay for the Alpha-Stim device. You say that you are appealing the denial to reimburse 
you $840 for this important and very helpful device. Plan representatives told you multiple times that your out-
of-pocket expense would be reimbursed. The Plan denied your request. The Plan says this item and related 
supplies does not meet the definition of DME as this item is not primarily and customarily used to serve a 
medical purpose and is useful to a person in the absence of disease. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the cranial electrotherapy stimulation (ces) system, includes all 
supplies and accessories, any type (K1002) provided December 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on May 2, 
2022, to May 23, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0299, & Q5001 are not supported in the medical record. Specifically, there was no 
Notice of Admission submitted for the dates of service at issue. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services (G0299, Q5001) provided on May 2, 2022, to May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0836, E2361, 
E1028, E1002). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the documentation 
provided for the wheelchair and accessories are medically necessary to meet the enrollee's current needs. The 
Plan denied your request. The Plan says the enrollee does not have a medical need for single power option 
included with a power wheelchair. As the enrollee does not qualify for the wheelchair base, none of the 
requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found a group 2 PWC 
can be covered if the medical necessity for a PWC is met and if the enrollee also requires a drive control 
interface, power tilt or a power recline seating system and if there has been a specialty evaluation that was 
performed by a licensed/certified medical professional, such as a physical or occupational therapist. In this 
case, the documentation indicates the enrollee is able to ambulate and accomplish self-care tasks in the home 
without a PWC to assist. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0836, E2361, E1028, E1002).
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 
December 28, 2021, to December 31, 2021. 
 
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 determination to remove principal and secondary diagnosis codes A41.9 (sepsis, unspecified organism) and R65.20 (severe sepsis without septic 
shock) are upheld. 
 
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 diagnosis codes A41.9 and R65.20. 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 the documentation showed normal kidney function, normal liver function, no 
hypoxia, normal platelets, normal urine output, and normal blood pressure. Records stated the patient was 
confused, however, there was no report of a reduced GCS following initial treatment with fluids and 
antibiotics. There was insufficient support for sepsis being present and related to the patient's infection. Sepsis 
3 criteria was not met. Therefore, the provided records do not sufficiently support the primary diagnosis of 
sepsis or the secondary diagnosis of severe sepsis.  
 
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 December 28, 2021, to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
20, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you pay $0 for an office 
visit for a doctor that is in-network. You also say that your office visit was not with a specialist. 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 a $20 
copayment for services obtained from a specialist. 
 
You have been asked to pay a $20 copayment for a specialist office visit. This item/service falls within the 
services obtained from a specialist 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 a 
specialist office visit provided on May 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency care provided on June 16, 
2022. 
 
You asked the Plan to waive the copayment for the emergency care. You say that the cause of the emergency 
room visit was due to services rendered in the Uurgent care that you initially attended. 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 a $120 
copayment for Emergency care. 
 
You have been asked to pay a $120 copayment for the emergency care. This item/service 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 copayment for the emergency care 
provided on June 16, 2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services provided on 
June 27, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that the nurse was not 
able to complete the procedure that day. 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 a $50 
copayment for services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery. 
 
You have been asked to pay a $50 copayment for the outpatient hospital services. This item/service falls within 
the services in an emergency department or outpatient clinic, such as observation services or outpatient surgery 
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 the outpatient hospital services 
provided on June 27, 2022.