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

 
We decided that the Plan does not have to pay for ambulance service, advanced life support, non-emergency 
transport, level 1 (A0426, A0425) provided on May 8, 2022. 
 
You asked the Plan to pay for ambulance service, advanced life support, non-emergency transport, level 1. You 
say that ambulance service, advanced life support, non-emergency transport, level 1 was medically necessary. 
The Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for ambulance service, advanced life support, 
non-emergency transport, level 1. Our reviewer says that ambulance service, advanced life support, non-
emergency transport, level 1 was not medically necessary. Our physician reviewer found that based on the 
medical records provided there is no documentation that the non-emergency ambulance transport was medical 
necessary. The provided records do not document that the hospital where the enrollee was being evaluated was 
unable to manage her condition and the enrollee was transferred to another hospital by ambulance based on her 
own stated preference to see her usual cardiologist.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, advanced life support, non-emergency transport, level 1 
have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced 
life support, non-emergency transport, level 1 (A0426, A0425) provided on May 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza. 
 
You asked the Plan to pre-approve Qutenza. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Qutenza. Our reviewer says that 
Qutenza is not medically reasonable and necessary in this case. Our physician reviewer found that the use of 
Qutenza (capsaicin) 8% topical system for treatment of hereditary and idiopathic neuropathy, is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
Quetenza also does not meet Medicare criteria for safe and effective and otherwise reasonable and necessary 
for this 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 Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Qutenza.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99358 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for code 99358. You say that this code was denied in error. The medical record 
contains information from the patient's previous office visit and is highlighted as such. Code 99358 clearly and 
correctly describes the services performed. The Plan denied your request. The Plan says that code 99358 is not 
supported in the medical record. 
 
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 99358 is Prolonged E/M before and/or after direct patient care; first hour. 
 
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 code 99358. Our reviewer says that code 99358 is supported 
in the medical record. Our reviewer found the provider documents that they spent 31 minutes non-face-to-face 
time reviewing patient records and the medical plan. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99358 have been met. Therefore, we decided that the Plan has to pay for 
code 99358 billed for date of service July 5, 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 hearing aids (V5261) provided on April 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you feel you should be reimbursed. The Plan 
denied your request. The Plan says this service is not covered because it was provided OON. 
 
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 the hearing aids (V5261) provided on April 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 10, 2022, 
through March 11, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim was not billed correctly. 
 
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 home health services have not been met. As per review of final 
claim, entered the admit date i.e., October 13, 2021. The provider submitted NOA with date of service January 
11, 2022. Per Medicare guidelines, you need to submit a valid NOA claim with From Date that matches the 
Admit Date on the Final Home Health claim i.e., October 13, 2021. Therefore, we find the Medicare rule for 
payment of this February 10, 2022, through March 11, 2022, claim has not been met and could not be 
processed for payment. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from February 10, 2022, through March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 2, 2022.
You asked the Plan to pay for this claim. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says The Plan denied your request. The Plan says documentation does not
support the billed services. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus applied the incorrect criteria.
The Plan is correct in this case. 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. There is insufficient information in the record
to determine if Medicare rules for coverage of genetic testing (81479) have been met. The information
provided with the claim and submitted independently to Maximus was incomplete or illegible. In addition,
much of the documentation was limited to lab results and medical literature. Therefore, we decided that the
Plan does not have to pay for genetic testing provided to the enrollee on March 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 7, 2022, to 
March 8, 2022. 
 
You asked the Plan to pay for home health services. You say that this is not a new admission and does not need 
an NOA. The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving home health 
services in 2021 whose services will continue in 2022, the home health agency (HHA) shall submit a Notice of 
Admission (NOA) with a one-time, artificial 'admission' date corresponding to the "From" date of the first 
period of continuing care in 2022. The HHA should submit the same admission date on all subsequent claims 
until the beneficiary is discharged and another NOA is required. We looked at the file and Medicare rules. The record shows that the final claim was not submitted with the 
same admission date as the NOA. Based on this information, we decided that Medicare rules for coverage of 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided from February 7, 2022, to March 8, 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 May 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. 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 May 16, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81519) provided on June 24, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. There were network providers 
available with comparable testing. 
 
The Plan follows Medicare rules. Medicare rules say that Oncotype DX Breast genetic testing is covered when 
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 genetic testing. Our reviewer says that 
the genetic testing was medically necessary. Our physician reviewer found Oncotype DX testing is endorsed by 
National Comprehensive Cancer Network guidelines. The testing offered by network providers may not give 
the same recurrence score which is needed to assess the need for adjuvant chemotherapy. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for genetic testing (81519) provided on June 24, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued home health care services provided from 
March 3, 2022, to March 18, 2022. 
 
You asked the Plan to pay for the continued home health care services. You say that you are requesting 
reconsideration of payment based on the medical necessity of the service provided. The Plan denied your 
request. The Plan says the appeal is lacking physical therapy notes to help determine medical necessity of 
therapy for the dates being appealed. The Plan also says complete notes are required for medical necessity 
review. 
 
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 pay for the continued home health care services. Our 
reviewer says that the continued home health care services were not reasonable and necessary for the enrollee. 
Our physician reviewer found the enrollee did not have documented skilled physical therapy needs. 
 
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 continued home health care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the continued home health care services provided from March 3, 
2022, to March 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot (J9217). 
 
You asked the Plan to pre-approve Lupron Depot. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Lupron Depot (J9217).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sterile gloves (A4930) provided on June 10, 2022. 
 
You asked the Plan to pay for the sterile gloves. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Medically Unlikely Edits (MUE) value is 
listed as 0 (zero), the procedure code is invalid, not covered, bundled, not separately payable, statutorily 
excluded, or not reasonable and necessary. 
 
We looked at the file and Medicare rules. The code billed has a MUE of 0 and is not eligible for payment. 
Based on this information, we decided that Medicare rules for coverage of the sterile gloves have not been met. 
Therefore, we decided that the Plan does not have to pay for sterile gloves (A4930) provided on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, 
MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, 
each specimen provided to the enrollee on July 20, 2022. 
 
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 this should not be reported separately. 
 
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 services 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 mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, 
QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen provided to the 
enrollee on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on February 22, 
2022. 
 You asked the Plan to pay for definitive drug testing. You say that this test was necessary and was ordered by 
the enrollee's physician. The Plan denied your request. The Plan says the documentation provided does not 
support that the criteria for coverage of this test have been met. 
 
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. The rules also say that definitive drug testing is indicated when certain criteria 
are met. 
 
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 definitive drug testing have been met. 
Specifically, there is no documentation to show that the results of a presumptive screen were positive or that 
there was a presumptive screen which was negative but inconsistent with the enrollees medical history. There 
is no indication that a presumptive test was not available. Therefore, we decided that the Plan does not have to 
pay for definitive drug testing (G0483) provided on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on April 12, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you were told at the store that the socks 
would be covered by your health insurance. You could have purchased the 2 pairs of socks for $20 combined 
and would have had you known this situation would have occurred. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested treatment is medically 
necessary due to chronic pain syndrome. The Plan denied your request. The Plan says the records show this 
device is not a late or last resort because the enrollee is a surgical candidate. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is covered for certain 
indications and when 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 a spinal cord stimulator. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found detailed documentation is 
not evident regarding this request being a late option after more conservative attempts such as medications, 
physical therapy, psychological therapy or other modalities have been tried. There is no detailed documentation 
of psychological therapy having been tried or a psychological screen having been performed. Moreover, careful 
screening, evaluation, and diagnosis by a multidisciplinary team are not documented. Overall, there is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to the hospital on November 21, 2022 with pneumonia. 
The physical therapy note dated November 25, 2022 states she is walking 150 feet in the hall with stand-by 
assist. She was discharged with home health. The documentation does not support that the enrollee has skilled 
nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a 
practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0279 billed for date of service July 13, 
2022. 
 You asked the Plan to pay for procedure code G0279. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0279 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0279 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0279 billed for date of service July 13, 2022.