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

 
We decided that the Plan does not have to pre-approve pool therapy (97113, 97162). 
 
You asked the Plan to pre-approve pool therapy. You say that you have been currently treated for inflammation 
of the right sacroiliac joint and other issues. A spinal cord stimulator has been implanted in your back. You also 
say this therapy is necessary. The Plan denied your request. The Plan says there is no indication of pool therapy 
for the inflammation of your joint in which the lower spine and pelvis connect. 
 
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 pool therapy. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records did not clearly show that you were not able to perform land-based therapy 
as required to meet criteria for aquatic therapy. Therefore, without sufficient support provided for this request, 
the pool therapy will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pool therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pool therapy (97113, 97162).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported as billed. 
 
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 provided on 
January 17, 2022 have been met. The provider did not send records to support that the testing was performed and how many units were provided. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 88342. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 88342 is bundled into payment for code 88361. 
 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 88342 
is a column II code to column I code 88361. 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 88342 billed for date of service April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on May 19, 
2022. 
 
You asked the Plan to waive the deductible for laboratory services. You say that the provider ordered the 
services without knowing if they would be covered 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 $35.09 
deductible for outpatient diagnostic test. 
 
You have been asked to pay a $35.09 deductible for laboratory services. This item/service falls within the 
outpatient diagnostic test 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 deductible for laboratory 
services provided on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 provided on April 11, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the out-of-network (OON) specialist visit 
provided on June 16, 2022. 
 
You asked the Plan to reduce the copayment for the out-of-network (OON) specialist visit. You say that the 
provider should be considered in-network. 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 $65 
copayment for out-of-network provider and professional services. 
 
You have been asked to pay a $65 copayment for the out-of-network (OON) specialist visit. This item/service 
falls within the out-of-network provider and professional 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. The file shows that the Plan verified the provider is 
not a network provider. Therefore, we decided that the Plan does not have to reduce the copayment for the out-
of-network (OON) specialist visit provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on 
December 28, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level 
of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 
provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99401 provided on January 9, 2022. 
 
You asked the Plan to pay for procedure code 99401. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 CPT code 99401 is not supported in the medical record. Specifically, procedure code 99401 has a 
status code of N under the Physician Fee Schedule and is a non-covered service per Medicare guidelines. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99401 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99401 provided on January 9, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ambulance services provided on May 13, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Ambulance services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 Ambulance services provided on May 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care coded 99310 provided on 
March 4, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99310 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive 
interval history; A comprehensive examination; Medical decision making of high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may 
be unstable or may have developed a significant new problem requiring immediate physician attention. 
Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit.  
We find that CPT code 99310 is not supported in the medical record. Specifically, the clinical information 
provided indicates that the enrollee is on palliative care with a follow up visit with stable established problems 
of chronic conditions and other established follow-up diagnoses. This means there is a more appropriate code 
to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage 
of the subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not have to 
pay for the subsequent nursing facility care coded 99310 provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM sensor. You say that the enrollee has been 
using the Freestyle Libre to check his blood since May 2020. Due to the enrollees medical condition, he would 
highly benefit from using the Freestyle Libre since it will be easier for him to check his sugars daily. The Plan 
denied your request. The Plan says the enrollee does not meet coverage criteria for approval of this CGM 
device. Medicare requires that the enrollee is insulin-treated with multiple (three or more) daily administrations 
of insulin and the beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on 
the basis of blood glucose monitor (BGM) or CGM testing results. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14-day CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre 14-day continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC Hematology Profile provided on July 22, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that there are Medicare coverage 
determinations which indicate that panels that include FANCC and BLM genes are noncovered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are noncovered, we find there is no basis to overrule the specific coverage decision made by the 
MolDX contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile have been met. Therefore, we decided that the Plan has to pay for the 
GTC Hematology Profile provided on July 22, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that your doctor was not available 
and you were advised to go to the urgent care center. 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 the urgent 
care visit provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture for the upper jaw (D5110). 
 
You asked the Plan to pre-approve a complete denture. You say that your current dentures are getting old and 
need to be replaced. The Plan denied your request. The Plan says dentures are not covered by your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete denture for the upper jaw (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological procedure provided on 
February 01, 2022, to March 15, 2022. 
 
You asked the Plan to waive the copayment for ophthalmological procedure. You say that you were not 
charged these copayments at the time of the visit. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for ophthalmological procedure. This item/service falls within 
the physician/practitioner services, including doctors office visits 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. You had two visits ($40 x 2 = $80), which means 
you have a total copayment of $80. Therefore, we decided that the Plan does not have to waive the copayment 
for ophthalmological procedure provided on February 01, 2022, to March 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on April 15, 
2022. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that the provider didn't tell you 
that there would be a copayment for this test. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services.  
 
You have been asked to pay $96.70, which is less than the original copayment of $100 for a breast ultrasound. 
This item/service falls within the outpatient diagnostic tests and therapeutic 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 a breast ultrasound provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96365 billed for date of service January 21, 
2022. 
 
You asked the Plan to pay for procedure code 96365. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 96365 is bundled into payment for code 74177.  
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 96365 
is a column II code to column I code 74177. 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 96365 billed for date of service January 21, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from February 1, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) stay. You say that you had 
terrible treatment through this stay and do not feel you should have to pay this huge payment. 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 $188 
copayment per day for days 21 - 100 for skilled nursing facility (SNF) care. You were charged until you 
reached you out-of-pocket maximum of $2900. You are being charged $2600.  
 
You have been asked to pay a $2600 copayment for a skilled nursing facility (SNF) stay. This item/service falls 
within the skilled nursing facility (SNF) 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 a skilled nursing facility (SNF) stay provided 
from February 1, 2022, to February 28, 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.