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

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on July 22, 
2022, to July 23, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for Ambulance services. 
 
You have been asked to pay a $225 copayment for ambulance transport. This item/service falls within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. You have been asked to pay a $675 ($225 x3 trips) copayment for your ambulance transports. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance transport provided on 
July 22, 2022, to July 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), anesthetic agent(s) and/or steroid; intercostal 
nerve, single level (CPT code 64420-59 LT) provided on December 14, 2021. 
 
You asked the Plan to pay for the service. 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, the CPT Code Manual definition of code 64420 is injection(s), anesthetic agent(s) and/or steroid; 
intercostal nerve, single level. 
 
The physician injects one or more anesthetic agents and/or steroids near the intercostal nerves, which are located underneath the ribs, to alleviate pain and inflammation often caused by a herpes zoster infection 
(shingles) or a surgical incision. In 64420, a single level is injected. Therefore, the provider should use CPT 
code 64421 for each additional level injected. Therefore, we decided that the Plan does not have to pay for 
injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level (CPT code 64420-59 LT) 
provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services provider was medically necessary. 
The Plan denied your request. The Plan says there was no prior authorization on file for the services provided. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 18, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services at an Intensive Care Unit rate provided 
from April 24, 2022, to May 10, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at an Intensive Care Unit rate. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the 
services are not supported as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, it is unclear what services are at issue in this appeal request. The 
provider is appealing inpatient facility services provided from April 24, 2022, to May 10, 2022. The Plan states 
at issue is a level of care determination. The Plan goes on to state that the dates of service from May 2, 2022, to 
May 4, 2022, should have been billed at an Intermediate/Step-down Unit level of care rate. The Plan then states 
upon review, they have reversed the prior determination regarding level of care coverage and the the enrollee's 
overall condition warranted active and ongoing management at the intensive care unit level of care through 
May 4, 2022. The Plan has not clarified what dates of service are being appealed, or if the issue of appeal 
remains to be an intensive care unit level of care for the entire stay, or from dates of service May 5, 2022, to 
May 10, 2022. Therefore, we decided that the Plan has to pay for the inpatient hospital services at an Intensive 
Care Unit rate provided from April 24, 2022, to May 10, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from May 24, 2022, to June 22, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee's condition no 
longer required daily skilled services at an inpatient skilled nursing facility. 
 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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 pay for SNF care provided from May 24, 2022, to June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the limited oral evaluation-problem focused 
(D0140) and the osseous surgery-four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) 
provided on May 9, 2022 and May 25, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. Additionally, services are only covered when received by a participating provider. 
 
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 services provided are not among 
those covered under this benefit. Additionally, services are only covered when received by a participating 
provider. Therefore, we decided that the Plan does not have to issue reimbursement for the limited oral 
evaluation-problem focused (D0140) and the osseous surgery-four or more contiguous teeth or tooth bounded 
spaces per quadrant (D4260) provided on May 9, 2022 and May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the Plan's denial is false and 
fraudulent. The Plan denied your request. The Plan says you do not have a qualifying wound for coverage of 
compression stockings. 
 
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 pre-approve compression 
stockings identified with code A6530.  
 
Your complaint about your experience with the Plan and with Maximus is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 16, 2022, billed with 
codes 81455, 81301, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 16, 2022, billed with codes 81455, 81301, and 81194.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal follow up appointment (D4910) provided by an 
out-of-network provider on August 31, 2022 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or 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 pay for periodontal follow up appointment (D4910) provided by an out-of-network provider on August 31, 
2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 18, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration 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 lab testing provided on 
August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
enrollee did not obtain improvement in pain or function for more than 2 weeks from the ESI performed on 
November 16, 2022 and the provider plans to use the same level, approach, and medication with the repeat 
injection. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4624, E0700, 99072, A4556, A4557, 
A4649, A9279, S1015 and S8301 billed for date of service August 3, 2022. 
 
You asked the Plan to pay for procedure codes 99072, A4556, A4557, A4649, A9279, S1015 and S8301. You 
say that the services at issue have been billed correctly. The Plan denied your request. The Plan says the billed 
codes are invalid for Medicare purposes or are considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. Procedure codes 
A4556, A4557 and A4649 have a status indicator of P on the Physician Fee Schedule. This means that 
procedure code 99072 and procedure codes A4556, A4557 and A4649 are not separately payable. Procedure 
codes A9279, S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure codes A9279, S1015 and S8301 are not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99072, A4556, A4557, A4649, A9279, S1015 and 
S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4624, 
E0700, 99072, A4556, A4557, A4649, A9279, S1015 and S8301 billed for date of service August 3, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 you appear to be improving and require additional short term acute care services that 
can be safely administered at the current facility until more stable and appropriate for a lower 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7210, D7953) provided on June 21, 2022. 
 
You asked the Plan to pay for the dental 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 do not fall 
within your plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services (D7210, D7953) 
provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism provided on August 22, 2022. 
 
You asked the Plan to pay for the seat lift mechanism. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the durable medical equipment (DME) supplier 
is 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 seat lift mechanism provided on 
August 22, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87641, 87486, 87502, 
87581, U0004, 87541, 87496, 87498, 87532, 87798 and 87801. We decided that the Plan does not have to pay 
for the services described by procedure code(s) 87634.  
 
You asked the Plan to pay for laboratory services provided on January 10, 2022. You say that these services 
were necessary and are supported as billed. The Plan says that the payment for code 87634 is included in the 
payment for code 87631. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87641, 87486, 87502, 
87581, U0004, 87541, 87496, 87498, 87532, 87798 and 87801.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 87641, 87486, 87502, 87581, 
U0004, 87541, 87496, 87498, 87532, 87798 and 87801.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
87634. 
 
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 87634 
is a column II code to column I code 87631. 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 services described by procedure code(s) 87634. 
 
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 eyewear provided on August 12, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you would like a reimbursement of $295 for your 
eyewear. The Plan denied your request. The Plan says the provider was out-of-network. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you see an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyewear provided on August 12, 2022.