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

 
We decided that the Plan does not have to pay for the genetic testing services (81206 and 81292) provided on 
September 3, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the claim has not been billed as 
required by Medicare billing regulations. 
 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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206 and 81292) provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing provided on December 15, 2021. 
 
You asked the Plan to pay for the testing services. You say that drug testing is needed to monitor opioid abuse. 
The Plan denied your request. The Plan says the service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. We find that the testing described by the billed code is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the validity testing provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal 
abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures 
(D0431) provided on March 7, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the plan's denial 
for payment. The Plan denied your request. The Plan says that the service at issue is not a covered benefit 
under your contractual policy. 
 
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 Plans contract and Dental care offering statement does not 
sufficiently indicate covered dental services. The Plan has not substantiated their denial; therefore, we must 
find in your favor. Therefore, we decided that the Plan has to pay for the adjunctive pre-diagnostic test that aids 
in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or 
biopsy procedures (D0431) provided on March 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bed rail, toilet seat, and hip kit purchased on July 15, 2021 to 
August 18, 2021. 
 
You asked the Plan to pay for these services. You say that you needed the items to help with activities of daily 
living. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Furthermore, the 
items were purchased from a provider not certified by Medicare. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for bed rail, toilet seat, and hip kit purchased on July 15, 2021 to August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interim caries medicament application (D1354) for 
tooth #2 & #9. 
 
You asked the Plan to pre-approve the medicament application. The Plan denied your request. The Plan says 
this service is not covered under the enrollee's supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
interim caries medicament application (D1354) for tooth #2 & #9.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cancer treatments from October 14, 2019, 
to December 9, 2019. 
 
You asked the Plan to waive the copayments for cancer treatments. You say that you thought that the Plan had 
taken care of these copayments, and that you cannot afford them. The Plan denied your request. The Plan says 
the copayment amount 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 a $60 
copayment for diagnostic radiology. You had 39 visits x $60 per visit = a total of $2340. 
 
You have been asked to pay $2340 copayment for cancer treatments (39 x $60 = 2340). Cancer treatment falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for cancer treatments from October 
14, 2019, to December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 15, 
2021, and an extraction of tooth #18 (D7210), fixed partial denture on tooth #20 (D9120), and deep sedation 
(D9222, D9223) provided on April 29, 2021. 
 
You asked the Plan to pay for an evaluation, denture, extraction, and sedation. You say that you were enrolled 
in the wrong plan. The Plan denied your request. The Plan says you do not have an active dental plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The record shows your cancellation with the Plan was effective January 1, 2021. 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 a limited oral evaluation (D0140) provided on 
April 15, 2021, and an extraction of tooth #18 (D7210), fixed partial denture on tooth #20 (D9120), and deep 
sedation (D9222, D9223) provided on April 29, 2021.  
 
 Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the CMS Regional Office so that it can look into your enrollment question.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a postoperative follow-up visit, normally included in the 
surgical package, to indicate that an evaluation and management service was performed during a postoperative 
period for a reason(s) related to the original procedure (99024) provided on March 15, 2022. 
 
You asked the Plan to pay for a postoperative follow-up visit. You say that you disagree with the cost share, 
and you are requesting reconsideration of the charges. The Plan denied your request. The Plan says this service 
is included in another service provided to you at the same time by the same provider. The Plan also says you 
are not responsible for this copayment. 
 
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 CPT code 99024 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99024 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of a postoperative follow-up visit have not been met. Therefore, we decided that the Plan does not have to pay 
for a postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and 
management service was performed during a postoperative period for a reason(s) related to the original 
procedure (99024) provided on March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on May 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that due to the setting of the 
services, it is not always possible to obtain an authorization for every visit prior to the services being rendered. 
The Plan denied your request. The Plan says authorization was not obtained before the services were rendered 
to the enrollee. 
 
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 in this case is not a network provider with the Plan. 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 rest home visit provided on May 15, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denied claim. The 
Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 laboratory services provided on January 26, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210), comprehensive oral evaluation (D0150), and the prophylaxis (D1110) provided on January 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiographic images, oral evaluation, and prophylaxis. The Plan denied your 
request. The Plan says these services have been provided out-of-network and were not approved in advance. 
 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 Plan covers certain dental 
services when they are provided in-network with the Plan. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage have not been met because the services were provided out-of-network with the Plan. Therefore, we 
decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210), 
comprehensive oral evaluation (D0150), and the prophylaxis (D1110) provided on January 11, 2022, by an out-
of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CologuardTM colorectal cancer screening (81528) provided 
on December 6, 2021. 
 
You asked the Plan to pay for CologuardTM. You say that this service is eligible for Medicare payment and 
should be paid. The Plan denied your request. The Plan says there is insufficient information to verify that 
Medicare criteria are met for this service. 
 
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. 
 
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 a CologuardTM colorectal cancer 
screening have been met. Specifically, no medical records were provided to verify that the criteria for coverage 
of this screening have been met. It is also unclear what provider referred these services for the enrollee. 
Therefore, we decided that the Plan does not have to pay for a CologuardTM colorectal cancer screening 
(81528) provided on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of support implant (20680-RT-XS) provided on 
August 4, 2021. 
 You asked the Plan to pay for removal of support implant. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says payment for this service is inclusive to 
another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 20680 is a column II code to column I code 27447; however, 20680 
was billed with a modifier.  
 
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 removal of support implant. Our reviewer says that the 
documentation does not support separate payment for CPT code 20680. Our reviewer found the operative 
report describes hardware removal right femur, and total knee arthroplasty (TKA). In this case, removal of 
hardware would be performed in order to perform the primary procedure. Therefore, CPT 20680 would be 
inclusive to CPT 27447 and not eligible for separate payment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of removal of support implant have not been met. Therefore, we decided that the 
Plan does not have to pay for removal of support implant (20680-RT-XS) provided on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), electronic connection (E2311) 
and expandable controller harness (E2313). 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that that your upper extremity function is adequate to control the power 
options using their own switches. 
 
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 pre-approve these items. Our reviewer says that the 
requested items are considered medically reasonable and necessary in this case. There are 3 or more power 
functions, and there is clinical documentation of spasticity and limitations of range of motion in upper limbs. 
Our physician reviewer found that your condition meets criteria for coverage of these items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have been met. Therefore, we decided that the Plan has to pre-
approve an expandable controller (E2377), electronic connection (E2311) and expandable controller harness 
(E2313).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (K0553) provided December 9, 2021. 
 
You asked the Plan to pay for the diabetic supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The delivery record shows the delivery was made to 
Florida, however the enrollee's address is in Texas. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for diabetic supplies (K0553) provided December 9, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the venography (75820). We decided that the Plan does not have to pay 
for the transcatheter retrieval (37197).  
 
You asked the Plan to pay for the transcatheter retrieval (37197) and venography (75820). You say that CPT 
code 37197 is separately billable and CPT code 75820 was necessary to formulate a plan of treatment for the 
thrombus. You say that you disagree with the denials. The Plan says procedure codes 37212 and 36010 were 
approved. The Plan also says procedure code 37197 is not supported by the medical records submitted and 
procedure code 75820 is considered inclusive to CPT code 37187. 
 
We decided that the Plan has to pay for the venography (75820).  
 
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 venography (75820). Our reviewer says that the medical 
coding does support the use of procedure code 75820-26-XU. Our reviewer found that procedure code 75820 
does show an edit relationship with procedure codes 37187, but you can override the edit with having a 
modifier on procedure code 75820. Therefore, we decided that the Plan has to pay for the venography (75820).  
 
We also decided that the Plan does not have to pay for the transcatheter retrieval (37197). 
 
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 transcatheter retrieval (37197). Our reviewer says that the 
medical documentation does not support the use of code 37197. Our reviewer found that the provider did not 
document any foreign body removal such as a broken venous or arterial catheter. Therefore, we decided that 
the Plan does not have to pay for the transcatheter retrieval (37197). 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on November 29, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
services are not a Medicare benefit for the diagnoses listed on the claim. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the services by a contract provider. The file does not show that the plan provided 
notice that the services would not be covered. Under Medicare rules, this means the services are considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the lab services provided 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.