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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81162, 81194, 81206, 
81235, 81292, 81295, 81298, 81301, 81309, 81317, 81321, and 81402) provided on May 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 81162, 
81194, 81206, 81235, 81292, 81295, 81298, 81301, 81309, 81317, 81321, and 81402, remain not supported. 
The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen 
was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 
81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in a place of service 11 and 22; therefore, the billed code cannot be verified. It is noted multiple 
attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code(s): 81162, 81194, 81206, 81235, 81292, 81295, 
81298, 81301, 81309, 81317, 81321, and 81402) provided on May 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan 
provided on December 11, 2021, billed with code 70450. 
 You asked the Plan to pay for the CT interpretation. You say that this was medically necessary. The Plan 
denied your request. The Plan says a required modifier was not reported. 
 
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 70450 
is a column II code to column I code 70496. 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 the interpretation of the computed tomography (CT) scan 
provided on December 11, 2021, billed with code 70450.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Freestyle Libre 14-day Sensor (CPT code
K0053), for the enrollee.
You asked the Plan to provide coverage for the Freestyle Libre 14-day Sensor (CPT code K0053). You say that
this equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says all of the
required coverage criteria regarding insulin usage are not met. Maximus overturned the Plans denial stating the
equipment would be beneficial for the enrollee. The Plan requested a reopen and stated that Maximus did not
adhere to the LCD criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that all of the
required LCD criteria must be med for coverage. The records show the enrollee does not take insulin more than
twice daily and the enrollee does not make frequent insulin treatment regime changes.
The medical records show the basal insulin dose was changed once last year to address low blood sugar with no
changes since. Based on this information, we decided that Medicare rules for coverage of this equipment are
not met. Therefore, we decided that the Plan does not have to provide coverage for the Freestyle Libre 14-day
Sensor (CPT code K0053), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that you are improving but still require ongoing acute care 
services before transitioning to a lower level of care.    You continue to receive acute care services, and these 
have not been denied. The medical record does not indicate that you require services that you are not currently 
receiving but that would be available at the LTACH facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided on August 6, 
2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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. In this case, we have confirmed that code 
710415 is a column II code to column I code 71046. 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 the chest x-ray (CPT code 71045) provided on 
August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of cast partial framework (D5622) and add tooth to existing partial denture (D5650 x 2).

You asked the Plan to pre-approve the dental services. You say that you need these teeth put into the partial. You also say that you need the partial repair so you can chew your food in order to survive. The Plan denied your request. The Plan says the requested services were denied correctly.

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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested repair of cast partial framework and add tooth to existing partial denture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve repair of cast partial framework (D5622) and add tooth to existing partial denture (D5650 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 82656, 83520, 83631, and 
87338) provided on August 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 83520, 
83631, 82656, and 87338 remain not supported. The place of service on the CMS-1500 form line 24B must 
reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory 
results submitted indicate the specimen was collected on August 10, 2021, and received by the lab on August 
11, 2021. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 
82656, 83520, 83631, and 87338) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on December 13, 2021, from an 
out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not notified that the benefits had 
changed. The Plan denied your request. The Plan says hearing aids must be purchased through the Plan's 
hearing vendor to be covered under the hearing aid services offered by your plan.  
Medicare rules say that plans can require enrollees to get hearing aids from the Plan's hearing vendor. The 
provider in this case is not the Plan's supplemental hearing vendor. Therefore, we decided that the Plan does 
not have to pay for the hearing aids purchased on December 13, 2021, from an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram and moderate sedation services 
provided to the enrollee on August 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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 the denied codes is: 
 
CPT 93010: 
 
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 
 
CPT 99152: 
 
 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 
 
CPT 99153: 
 
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; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
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 in terms of CPT 93010, the 
operative report does not support that an electrocardiogram (ECG) was performed as part of the anesthesia 
services, and therefore cannot be verified. In terms of CPT 99152 and 99153, the operative report does not 
include documentation of any moderate sedation. 
 
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 an electrocardiogram and moderate sedation services provided to the enrollee on August 6, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oximeter device for measuring blood oxygen levels 
(E0445). 
 
You asked the Plan to pre-approve a pulse oximeter. You say that the device is medically necessary. The Plan 
denied your request. The Plan says this device is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that oximeters are not covered because they are 
monitoring devices that provide information to the treating practitioner to assist in managing the beneficiarys 
treatment.  
 
While a pulse oximeter may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve an oximeter device for measuring blood 
oxygen levels (E0445).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services provided on September 23, 2021, 
billed with code 76770. 
 
You asked the Plan to pay for the ultrasound services as billed. You say that this was supported. The Plan 
denied your request. The Plan says this code is not supported by the records. 
 
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 76770 is Ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete. 
 
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 ultrasound services as billed. Our reviewer says that the 
billed code is not supported. Our reviewer found the documentation does not include enough detail to confirm a 
complete retroperitoneal ultrasound has been performed. Abdominal ultrasounds can be ordered a complete or limited. The abdomen limited includes images of the pancreas, liver, gallbladder, and right kidney. The 
abdomen complete includes imaging the aorta, IVC, pancreas, liver, gallbladder, right and left kidneys, and 
spleen. Therefore, this procedure cannot be confirmed. 
 
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 ultrasound services as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the ultrasound services provided on September 23, 2021, billed with code 
76770.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation is insufficient to 
demonstrate that an E0466 portable ventilator is medically reasonable and necessary for the enrollee in this 
case. It is not documented that the enrollee has failed treatment with BiPAP or CPAP. Products classified as 
E0466 when used to provide CPAP or bi-level PAP shall not be paid in the FSS payment category, regardless 
of the underlying medical condition. The documentation does not show that BiPAP with back-up rate or 
volume assured pressure support will not work 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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home mechanical (portable) ventilator (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve a targeted genomic sequence analysis panel provided to the 
enrollee on December 18, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that the cancer needs to be either recurrent, relapsed, refractor, metastatic, or advanced 
stay III or IV cancer and not been previously tested with the same test. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found per the National Comprehensive Cancer Network (NCCN) Guidelines for pancreatic cancer 
tumor/somatic molecular profiling is recommended for patients with locally advanced/metastatic disease who 
are candidates for anti-cancer therapy to identify uncommon mutations.  Testing on tumor tissue is preferred; 
however, cell-free DNA testing can be considered if tumor tissue testing is not feasible. This patient has 
recurrent pancreatic cancer and meets this criteria. The service is reasonable and medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve a targeted genomic sequence analysis panel provided to the enrollee on December 18, 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: Favorable

 
We decided that the Plan has to pay for an interval injection provided to the enrollee on November 29, 2021. 
 
You asked the Plan to pay for the injection. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the denial of the procedure was appropriate given the clinical scenario. 
 
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 pay for the injection. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee had bupvicaine and hydromorphone injected into the intra-thecal catheter. The procedure 
was medically reasonable and necessary as part of intra-thecal medication therapy. 
 
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 injection have been met. Therefore, we decided that the Plan has to pay for 
an interval injection provided to the enrollee on November 29, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 22, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the presence of modifier GY indicates this is not 
eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
By adding the GY modifier, the ambulance company has designated this trip as a non-billable service. The 
Health Plan is not able to cover claims submitted using the GY modifier. If the enrollee feels this modifier was 
used inappropriately, they will need to discuss the issue with the ambulance company. Because the GY 
modifier was used, the original denial of this request is appropriate. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided on January 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient Hospital stay from August 14, 
2021 through October 23, 2021. 
 
You asked the Plan to waive the copayment for Inpatient Hospital stay. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $350 
copayment each day for days 1 to 5 for Medicare covered hospital care. $0 copayment for additional Medicare-
covered days. for Inpatient Hospital stay. The total cost share is $1,750. 
 
 You have been asked to pay $350 copayment each day for days 1 to 5 for Medicare covered hospital care. $0 
copayment for additional Medicare-covered days. for Inpatient Hospital stay. Inpatient Hospital stay falls 
within the Inpatient Hospital 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 
Inpatient Hospital stay from August 14, 2021 through October 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on July 9, 2021, billed with code 83789. 
 
You asked the Plan to pay for the testing as billed. You say that this should be paid. The Plan denied your 
request. The Plan says the drug testing was paid, but no separate payment can be made for code 83789. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of the testing as billed have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for the unspecified mass spectrometry testing provided along with drug testing on 
July 9, 2021, billed with code 83789.