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

 
We decided that the Plan does not have to pay for laboratory services (80061, 84436, 36415, 80053) provided 
on January 25, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 (80061, 84436, 36415, 80053) 
provided on January 25, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 25, 
2022, by an OON provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the outpatient testing is medically 
necessary and reasonable to continue to evaluate, monitor, and treat the enrollee. The Plan denied your request. 
The Plan says the out-of-network services were not authorized. 
 
 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 a hospital outpatient clinic visit provided on 
January 25, 2022, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours per week of attendant care services 
(S5125). 
 You asked the Plan to pre-approve additional hours per week of attendant care services. You say that the 
enrollee needs more assistance. The Plan denied your request. The Plan says these services are not covered 
under the enrollee's plan. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional hours per week of attendant 
care services. Our reviewer says that additional hours per week of attendant care services are not reasonable 
and necessary. Our physician reviewer found the documentation does not show why the requested number of 
personal care attendant hours are currently medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional hours per week of attendant care services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional hours per week of attendant care 
services (S5125).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient and office visit provided on March 16, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient and office visit. You say that you spoke to a plan representative and 
were told the services were out-of-network. You say the provider told you they were never notified they were 
not in-network. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 an outpatient and office visit provided on March 
16, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a paravertebral facet joint injection. 
 
You asked the Plan to pre-approve a paravertebral facet joint injection. You say that a paravertebral facet joint 
injection is medically necessary. The Plan denied your request. The Plan says a paravertebral facet joint 
injection does not meet the Medicare criteria. The Plan follows Medicare rules.  
 
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 paravertebral facet joint injection. Our 
reviewer says that a paravertebral facet joint injection is not medically necessary. Our physician reviewer found 
that the Medicare LCD criteria requires 80% pain relief from each set of diagnostic MBBs.  Since only 50% 
was achieved, a second set is not medically unreasonable or 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 a paravertebral facet joint injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a paravertebral facet joint injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on September 8, 2021. 
 
  You asked the Plan to pay for the rotary wing air transport and rotary wing air mileage. You say that you 
believe this transport meets medical necessity guidelines. The Plan denied your request. The Plan says this 
request is not medically necessary because the records show the enrollee did not have a medical problem for 
which ground transport would have created a threat to their survival or health. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport and rotary wing 
air mileage. Our reviewer says that the rotary wing air transport and rotary wing air mileage was not medically 
necessary. Our physician reviewer found the documentation does support that the patient suffers from an illness 
or injury that contraindicates transportation by any means other than ambulance. The documentation does 
support that the transferring hospital did not have adequate facilities to provide the medical services needed by 
the patient as oral surgery specialty services at a higher level of care were only available at the receiving 
hospital. However, the documentation does not support that the patient's condition was such that the time 
needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the 
patient's survival or seriously endangered the patient's health. 
 
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 rotary wing air transport and rotary wing air mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary 
wing air mileage (A0436) provided on September 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942-26 billed for date of service June 22, 
2021. 
 
You asked the Plan to pay for procedure code 76942-26. You say that this is a payable code. The Plan denied 
your request. The Plan says payment for code 76942-26 is bundled into payment for code 36556.  
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 
76942-26 is a column II code to column I code 36556. 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 76942-26 billed for date of service 
June 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the facet joint injections (64493 and 64494) provided on July 22, 2021. 
 
You asked the Plan to pay for the facet joint injections (64493 and 64494). You say that 64494 is an add on 
code to 64493 and is based on the levels of the injections performed. You say that the claim should correctly be 
reviewed for additional payment. The Plan denied your request. The Plan says that an appropriate modifier was 
not billed with this code edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that plans must make 
reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied CPT code 64493 for a code pair edit with CPT code 
99214, which was paid. In this case, CPT code 64493 is the column I code and does not require a modifier to 
be paid. In addition, CPT code 64494 is an add on code and was billed with the appropriate primary procedure 
code. It is the burden of the Health Plan to substantiate their decision with evidence. In this case, the decision to 
not pay these codes has not been substantiated so we must find in your favor. Based on this information, we 
decided that Medicare rules for coverage of the facet joint injections (64493 and 64494) have been met. 
Therefore, we decided that the Plan has to pay for the facet joint injections (64493 and 64494) 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus augmentation with bone or bone substitutes for upper right quadrant (code D7952).

You asked the Plan to pre-approve the sinus augmentation (code D7952). You say that you would like this service approved. The Plan denied your request. The Plan says this service is not listed on the dental benefits chart and therefore, is not a covered service.

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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the sinus augmentation with bone or bone substitutes for upper right quadrant (code D7952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
purchased on March 12, 2022, from a provider not enrolled in Medicare. 
 
You asked the Plan to pay for the CPAP device. You say that you should be reimbursed for this equipment you 
purchased as it was necessary for your condition. The Plan denied your request. The Plan says payment cannot 
be made to a provider not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device purchased on March 12, 2022, from a provider not enrolled in Medicare.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on August 2, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a trigger point injection. 
 
You asked the Plan to pre-approve a trigger point injection. You say that a trigger point injection is medically 
necessary. The Plan denied your request. The Plan says a trigger point injection does not meet the Medicare 
criteria.  
The Plan follows Medicare rules.  
 
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 trigger point injection. Our reviewer 
says that a trigger point injection is not medically necessary. Our physician reviewer found that there is no 
physical exam that documents that the patient actually has trigger points. This could be shown by at least one 
of the following: 
1) pain in a specific spot when it is pressed, 
2) pain or tenderness that travels when a specific spot is pressed, or 
3) a muscle or nerve that does not work the way it is supposed to. 
Therefore, the requested injection is not supported and is not medically reasonable or 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 a trigger point injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a trigger point injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an external tremor stimulator of the peripheral nerves 
(K1018) provided on October 14, 2021. 
 
You asked the Plan to pay for an external tremor stimulator. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for the item at issue 
have not been met. 
 
  The Plan must follow Medicare rules. Medicare rules say that no reimbursement may be made for the 
stimulator or for the services related to its implantation since this treatment cannot be considered reasonable 
and necessary. Based on this information, we decided that Medicare rules for coverage of an external tremor 
stimulator have not been met. Therefore, we decided that the Plan does not have to pay for an external tremor 
stimulator of the peripheral nerves (K1018) provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Carotid Sinus Baroreflex Activation Device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence that this device works and is safe. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Baroreflex stimulation devices have been considered potential alternative treatments for resistant 
hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath 
the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers 
electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In 
August 2019 the FDA approved the system for use in patients with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection 
fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved cardiac 
levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the 
Barostim Neo system would not be considered medically reasonable and necessary in this patients clinical 
management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Carotid Sinus Baroreflex Activation Device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services provided on November 9, 2021. 
 You asked the Plan to pay for the services provided. You say that the enrollee has acupuncture benefits. The 
Plan denied your request. The Plan says the service is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The use of infrared is non-covered for the treatment of pain. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the infrared therapy services provided on 
November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 2,
2020, under code J2001.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct Medicare billing criteria.
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 and when required the
appropriate modifier. We show a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP)
edit exists between 20611 and J2001. This PTP edit has a modifier indicator of 1, which indicates modifiers
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code
edit. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for physician services provided to the enrollee on December 2, 2020, under code J2001.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
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. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. This means that the professional interpretation must be billed with 
modifier -26 for payment to be considered. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health visits provided 
from October 4, 2021, to February 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health visits. You say that these visits were 
all brief visits for medication. The Plan denied your request. The Plan says the copayment amounts you are 
being charged are correct. The Plan also says that they have reprocessed and waived the copayment for date of 
service August 13, 2021. 
 
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 $25 
copayment for each covered outpatient mental health care visit. There were 5 visits, resulting in a total 
copayment amount of $125. 
 
You have been asked to pay $25 copayment for each outpatient mental health visit. Outpatient mental health 
visits fall within the Outpatient Mental Health 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 outpatient mental health visits provided from October 4, 2021, to February 22, 2022.