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

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for the billed services. You say that multiple drugs were tested within different drug 
classes. The Plan denied your request. The Plan says the records do not support the billed code. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not 
show that 22 or more drug classes were ordered or tested.  
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code G0483 billed for date of 
service November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 17, 2021, coded as 81455.

You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plan's denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that the records show a comprehensive molecular profile was done. However, the code description is for a targeted genomic sequence analysis panel. The Plan notes the Medicare billing guidelines show codes 81445, 81450, and 81455 describe targeted genomic sequence analysis. Code 81445 applies to solid organ neoplasm type (5-50 genes) and 81450 applies to hematolymphoid neoplasm type (5-50 genes), while 81455 applies to the number of genes analyzed for either a solid or hematolymphoid neoplasm (51 or greater genes).
Providers/suppliers may not report 81455 with either 81445 or 81450, 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, these services were billed with the inappropriate testing type code, based on the medical records provide. Medicare rules for coverage of this claim are not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 17, 2021, coded as 81455.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular electrical stimulation (NMES) provided 
on October 19, 2022. 
 
You asked the Plan to pay for the NMES. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the service was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is limited 
to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or 
splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery. 
 
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 NMES. Our reviewer says that the service was not medically necessary. Our physician reviewer found the records do not document disuse atrophy 
where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-
neurological reasons for disuse atrophy; records document 5/5 bilateral lower extremity strength. 
 
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 NMES have not been met. Therefore, we decided that the Plan does not 
have to pay for the neuromuscular electrical stimulation (NMES) provided on October 19, 2022.
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 you were admitted with cervicothoracic spinal 
stenosis with myelopathy. The Plan denied your request. The Plan says there is no skilled nursing needs or 
skilled therapy needs are identified that require the requested level of care. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
cervical spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left hip arthroscopy psoas release. 
 
You asked the Plan to pre-approve left hip arthroscopy psoas release. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the requested left hip arthroscopy psoas release is not 
considered reasonable and necessary for this patient. This patient has a history of bilateral hip replacements and 
has left hip pain despite conservative management. The patient has not had any imaging study to confirm a 
diagnosis of impingement. 
 
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 left hip arthroscopy psoas release. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records show a diagnosis of tensonitis of the iliopsios. However, there is no imaging showing impingement, so this surgery is not considered 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 left hip arthroscopy psoas release have not been met. Therefore, we decided that 
the Plan does not have to pre-approve left hip arthroscopy psoas release.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that you are in extreme pain and need 
the MRI to be approved. The Plan denied your request. The Plan says an MRI of the cervical spine is not 
medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the cervical spine. Our 
reviewer says that the requested MRI of the cervical spine is not medically necessary. Our physician reviewer 
found that you have had shingles and continue to have pain in the left arm. There are no red flags such as poor 
reflex, weakness, or numbness. There is no record of cervical plain films being done. In addition, no 
conservative management such as physical therapy has been attempted. Therefore, you do not meet the medical 
necessity of the requested MRI. 
 
   
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 MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the cervical spine.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for 127 units of procedure code 00320 rendered on July 19, 2022 
 
You asked the Plan to pay for the units. You say that this should be paid for. The Plan denied your request. The 
Plan says that Current Procedural Terminology (CPT) code 00320 AA P3 (127 units) remains not supported 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 00320 is "Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of 
neck; not otherwise specified, age 1 year or older." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the units. Our reviewer says that the services at issue in this 
case were supported by the medical records. Our reviewer found that a full anesthetic record was present in the 
documentation. The procedure lasted 3.5 hours, so 127 units was correct to report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the units have been met. Therefore, we decided that the Plan has to pay for 127 
units of procedure code 00320 rendered on July 19, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) and the 
panoramic radiographic image (D0330) provided on January 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation provided was exhausted on date of service January 11, 2023.  Specifically, the Plan contract provides coverage for one emergency diagnostic exam every calendar year. You 
previously received this service on January 11, 2023, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Additionally, the record shows your benefit for the panoramic 
radiographic image provided was exhausted on date of service November 12, 2019. Specifically, the Plan 
contract states that a full mouth or panoramic radiographic image is covered once every five calendar years. 
You previously received a full mouth x-ray on November 12, 2019, less than five years prior, which was paid 
for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) and the panoramic 
radiographic image (D0330) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364) provided on September 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were referred to an out-of-network dentist by 
your assigned dentist and would like the Plan to cover your dental services. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because the cone beam is not covered by the Plan. 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0364) provided on September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient mental health stay provided on June 11, 2022, to 
July 13, 2022. 
 
You asked the Plan to pay for an inpatient mental health stay. You say that you have Medicaid, and this should 
be covered. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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 an inpatient mental health stay 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 pay for an inpatient 
mental health stay provided on June 11, 2022, to July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the testing was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be rendered by an out-of-network (OON) 
dental provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental services from an out-of-network provider are 
not covered by your supplemental benefits. 
 
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. 
 
 
  
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested services are not covered under this benefit when received from an 
out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve office visits to be 
rendered by an out-of-network (OON) dental provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 10, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic services 
provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ganglion impar block, an unlisted procedure, nervous 
system (64999). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says criteria has not been met because ganglion impar 
block does not have enough proof in medical information or research by specialists that describe the safety, 
value or effectiveness for this procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 We looked at the file and Medicare rules. HAYES (a rating system developed to reflect the strength and 
direction of the evidence regarding medical technologies) gives this a C rating. Because this proof does not 
exist and outcomes cannot be proven, the request is considered investigational. You need to provide 
documentation of evidence in peer reviewed literature (studies reviewed by expert doctors) that proves this 
procedure has beneficial (better) outcomes (results) compared with conventional (standard) treatment. Based on 
this information, we decided that Medicare rules for coverage of an injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ganglion impar block, an unlisted procedure, nervous 
system (64999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from March 8, 2022, to 
April 30, 2022. 
 
You asked the Plan to pay for the services. You say that medical records were sent for review. The Plan denied 
your request. The Plan says several items and services initially denied due to not having an itemized bill have now been identified as routine items and 
services or duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that after careful review of the 
itemized bill, the items denied with code G ($94,407.31) were denied correctly, as these charges are considered 
supplies, items and services that are necessary or otherwise integral to the provision of a specific underlying 
service and/or the delivery of such underlying service(s) are not separately payable. Additionally, the duplicate 
denied services were denied correctly as the provider report initial bilevel positive airway pressure/continuous 
positive airway pressure (BiPAP/CPAP) twice during the hospital stay. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services rendered from March 8, 2022, to April 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
October 12, 2022. 
 
You asked the Plan to pay for the supplies. You say that the supplies are necessary for the enrollee. The Plan 
denied your request. The Plan says the documentation submitted did not include a physician order for the billed 
date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the electrical stimulator supplies (A4595) provided on October 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you are requesting an additional 9.5 miles for a 
total of 59.5 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit 
limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when The Plan covers up to 72 one-way trips and each one-way 
trip must not exceed 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).