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

 
We decided that the Plan does not have to pay for the laboratory services coded as 80053, 80061, 81003, 
82043, 82306, 82607, 82746, 83036, 83735, 85025, 86703 and 86803 provided May 26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please see the attached medical records for 
this date of service and reprocess the claim. The Plan denied your request. The Plan says medical necessity 
cannot be established. 
 
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 laboratory services have been met. 
additional records were needed from the provider to determine how the enrollee came to the servicing provider 
or whether the services were medically necessary. The Plan made multiple attempts to obtain the needed 
records from the provider without success. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded as 80053, 80061, 81003, 82043, 82306, 82607, 82746, 83036, 83735, 85025, 86703 
and 86803 provided May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for culture, typing (87153) provided August 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the results of this testing was medically 
necessary to establish the appropriate individualized treatment Plan for this enrollee. Please reconsider and 
process. The Plan denied your request. The Plan says this service was billed incorrectly. 
 
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 87153 is culture, typing; identification by nucleic acid 
sequencing method, each isolate (eg, sequencing of the 16S rRNA gene). 
 
We find that CPT code 87153 is not supported in the medical record. Specifically, the attached medical records 
do not provide a proof of culture but only indicates NGS and PCR testing performed via a swab. 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 culture, typing (87153) provided August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 25, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service June 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 
 
 
  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is experimental. More research is needed to show safety 
and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 14, 2022, to 
September 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 14, 2022, to 
September 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for magnetic resonance imaging (MRI) with injection.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial for billing issues. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
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. Your contract with the Plan clearly says that you must pay $100 copayment for outpatient imaging such as an MRI and 20% coinsurance for Medicare Part B drugs.
The injection provided is indeed a separately payable Medicare Part B drug which requires a 20% coinsurance. 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 charged for magnetic resonance imaging (MRI) with injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear and interpretation billed with code 85060 for 
September 17, 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 procedure code 85060 is not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 was not performed to a hospital 
inpatient and is therefore not covered. 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 blood 
smear and interpretation billed with code 85060 for September 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for date of service July 12, 
2022, to July 20, 2022. 
 
You asked the Plan to pay for procedure code S9502. 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 S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9502 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9502 billed for date of service July 12, 2022, to July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 9, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 
81408, and  
81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the 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 
August 9, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 
81404, 81405, 81406, 81407, 81408, and  
81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 80048, 82746, 83021 and 
83540 provided March 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you tried to contact the enrollee for correct 
information but were not able to obtain this information timely. You tried to contact the physician office for the 
correct diagnosis but were not able to obtain this information timely. The Plan denied your request. The Plan 
says the corrected claim was received past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until August 23, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 80048, 82746, 83021 and 83540 
provided March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve the supplemental benefits. You say that you have chronic illness and other 
health issues. The Plan denied your request. The Plan says you do not meet criteria for expanded benefit. 
 
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 supplemental benefits. Our 
physician reviewer found you do not require intensive care management. You are not at high risk for 
hospitalization. You have a documented and active diagnosis for one or more of the qualifying comorbid and 
medically complex conditions. The conditions are not life threatening or significantly limit your overall health 
or function. 
 
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 supplemental benefits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance provided from June 24, 2022, to July 23, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used in the treatment of 
peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Per LCD L33829, the requested PCD coded E0675 is not covered. As 
such the related appliance (E0673) is also not covered. Based on this information, we decided that Medicare 
rules for coverage of the PCD and appliance have not been met. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance provided from June 24, 2022, 
to July 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) provided 
from May 26, 2022, to June 14, 2022. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used in the treatment of 
peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Per LCD L33829, the requested PCD coded E0675 is not covered. 
Based on this information, we decided that Medicare rules for coverage of the PCD have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) 
provided from May 26, 2022, to June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the upper complete denture (D5110) and implant supported denture-lower (D6111) provided on February 8, 2022.
You asked the Plan to provide additional payment for the upper complete denture and implant supported denture-lower. You say that this the is first time you have used your dental coverage since having this insurance. The Plan denied your request. The Plan says that you have exceeded your $2,000 maximum dental allowance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Plan rules state that there is a $2,000 combined allowance for supplemental preventative and comprehensive dental services every year.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The file shows that the plan has approved the maximum yearly benefit of $2,000 for dental services. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to provide additional payment for the upper complete denture (D5110) and implant supported denture-lower (D6111) provided on February 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
February 10, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says this 
freestanding emergency room is not a Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare says that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a video monitor, a call bell, baby monitors, and sensor pads 
purchased from June 1, 2021 to June 20, 2021. 
 
You asked the Plan to pay for a video monitor, a call bell, baby monitors, and sensor pads. You say that you 
would like to be reimbursed for this equipment. The Plan denied your request. The Plan says these receipts fall 
outside of the 365-day timeframe for submission of reimbursement requests. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim reimbursement for a video monitor, a call bell, baby monitors, and sensor pads 
was not filed until October 21, 2022. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a video monitor, a 
call bell, baby monitors, and sensor pads purchased from June 1, 2021 to June 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87798) provided on August 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported as billed. The Plan denied your request. The Plan says these services were referred by and performed 
by out-of-network providers. Out-of-network care is only covered in certain limited circumstances, which have 
not been met in this case. 
 
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 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 laboratory services (87481, 87798) provided on 
August 17, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) provided 
from April 6, 2022, to April 25, 2022. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used in the treatment of 
peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Per LCD L33829, the requested PCD coded E0675 is not covered. 
Based on this information, we decided that Medicare rules for coverage of the PCD have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) 
provided from April 6, 2022, to April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on April 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim is supported and should be paid. 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 (G0483) provided on April 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 27, 2022, to 
July 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 27, 2022, to July 
26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88304 provided on September 3, 2022. 
 
You asked the Plan to pay for procedure code 88304. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 27, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the 
same date. Based on this information, we decided that the Medicare rules for procedure code 88304 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88304 provided on 
September 3, 2022.