Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs. 
 
You asked the Plan to pre-approve wheelchair repairs. The Plan denied your request. The Plan says the cost of 
repairs exceeds the cost of a new chair. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
We looked at the file and Medicare rules. The documentation shows that the cost of repairs is more than the 
cost of new equipment. Based on this information, we decided that Medicare rules for coverage of wheelchair 
repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses provided on April 7, 2023. 
  
You asked the Plan to pay for the contact lenses. You say that you were reimbursed for eyewear in December 
2022, and you could not wait to get contact lenses until the following December. The Plan denied your request. 
The Plan says the benefit has been exhausted. 
 
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 up to $70 for eyeglasses every 12 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $70 towards eyeglasses on December 6, 
2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of 
the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact 
lenses provided on April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nitro rolling walker. 
 
You asked the Plan to pre-approve the requested walker. You say that this walker is stronger and durable. The 
Plan denied your request. The Plan says you were provided a walker appropriate for your condition. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 The file shows that you have that you were provided a walker in October 2022. The documentation does not 
show that your current walker is beyond repair. Your current walker serves the same purpose as the requested 
walker. Therefore, we decided that the Plan does not have to pre-approve a Nitro rolling walker.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional trips for routine transportation. 
 
You asked the Plan to pre-approve the 24 additional trips. You say that the services are medically necessary. 
The Plan denied your request. The Plan says you have 2 remaining trips before you have exhausted your 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 24 additional trips for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee cannot take a shower without 
sitting. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 64484. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 77003.  
 
You asked the Plan to pay for the medical services provided on July 18, 2022, billed with codes 64483-50, 
64484-50 (two units), and 77003-XU. You say that these services should be paid. The Plan says that code 
77003 cannot be paid as it was performed in a hospital setting and requires modifier -26. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 64484.  
 
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 claim was reprocessed on August 22, 2023, paying for 64483-50. Code 64484-50 (2 units) were again 
denied stating that the records submitted did not support the services billed. However, the records that the Plan 
attests to have reviewed to make this determination where not included in the case file submitted to Maximus. 
As such, we cannot confirm that the denial for 64484 was correct. Therefore, we decided that the Plan has to 
pay for the services described by procedure code(s) 64484.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
77003. 
 
The Plan follows Medicare rules. Medicare rules say that physician services provided in an ASC are subject to 
the same limitations as physician services in an inpatient hospital. The rules say that payment cannot be made  
for the TC of radiological services provided to hospital patients.  
 
We looked at the file and Medicare rules. Since this code was not billed with modifier -26, payment was 
requested for both the professional component and the TC. As such, it cannot be paid as billed. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 77003 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 77003. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 15-21 drug classes (G0482) 
provided April 18, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please see attached medical records showing 
drug screen was performed on date of service billed. The Plan denied your request. The Plan says the code 
billed is incorrect as the amount of drug classes tested do not match the range on the 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, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays and enzymatic methods (e.g., alcohol dehydrogenase)), (2) 
stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including 
metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, in this case, the records 
show there were 23 drug classes tested. Therefore, the correct code would be G0483 for definitive drug test, 22 
or more drug classes. Based on this information, we decided that Medicare rules for coverage of the laboratory 
service have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing, 15-21 drug classes (G0482) provided April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for these services. 2D oral/facial photographic images and oral 
hygiene instructions (D0350, D1330) provided on June 22, 2023. 
 
You asked the Plan to pay for these services. 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 dental benefits. 
 
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 pay for these 
services. 2D oral/facial photographic images and oral hygiene instructions (D0350, D1330) provided on June 
22, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 51729. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 51701.  
 
You asked the Plan to pay for procedure codes 51701 and 51729 provided on December 2, 2022. You say that 
you would like the Plan to reconsider their denial of payment. The Plan says that the services are not covered. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 51729.  
 
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) 51729.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
51701. 
 
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 51701 
is a column two code to column one code 51729 with a modifier indicator of 0. The column two code is 
therefore not payable. 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) 51701. 
 
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 procedure code A4223 billed for date of service May 4, 
2023. 
 
You asked the Plan to pay for procedure code A4223. You say that the item should be covered. The Plan 
denied your request. The Plan says procedure code A4223 is considered statutorily excluded from coverage. 
 
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 A4223 has a status indicator of X on the Physician Fee Schedule. This means that 
procedure code A4223 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code A4223 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4223 billed for date of service May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on April 6, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 
4, 2023, to March 16, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $350 
copayment per day for day 1-5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for day 1-5 for inpatient hospital care. The total amount 
you owe is $1,750 ($350 x 5 days = $1,750).This item/service falls within the inpatient hospital care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 4, 
2023, to March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 2, 2023, to May 5, 
2023, billed with evaluation and management (EM) code 99292 x3. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the number of 
units 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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that in this case, total time documented 
does not support 3 units for CPT 99292. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 2, 2023, to May 5, 2023, billed with 
evaluation and management (EM) code 99292 x3.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need an IRF admission because you are ready 
for the next level of care. You also say you cannot go home because you will be at risk for falling. The Plan 
denied your request. The Plan says the request for an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the evidence-based and clinical practice standards do not support that you require 
intensive or complex rehabilitation services. Rehabilitation may reasonably be provided at several levels of 
care and does not require an IRF admission. IRF admission is not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided on June 14, 2023. 

You asked the Plan to waive the cost sharing for the office visit. You say that this was your first time seeing 
this provider, and you have never had to pay for a wellness visit before. 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. Your 
contract with the Plan says that there is an $800 deductible which applies to doctor and other health care 
provider services. Your contract with the Plan says that you must pay 10% coinsurance for office visits. 
 
The records show that office visit was outside the scope of a wellness visit, and the office visit cost sharing was 
correctly applied. You have been asked to pay $58.21 towards the deductible. The item or service you asked 
the Plan to waive the cost sharing for falls within the doctor and other health care provider services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 
deductible which applies to doctor and other health care provider services. This cost sharing is a contractual 
obligation that had not been met at the time the office visit was received on June 14, 2023.  
 
You have also been asked to pay $6.47, which is 10% coinsurance of the allowed amount for the office visit 
($64.68 allowed amount x 10% coinsurance = $6.47). You have been asked to pay a total of $64.68 ($58.21 
deductible + $6.47 coinsurance = $64.68). 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 cost sharing for the office 
visit provided on June 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services coded A0427 for date of service June 
12, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the QL modifier should be billed with codes 
A0428 or A0429.  
 
We looked at the file and Medicare rules. Review of the file shows that the claim was billed with code A0427 
and modifier QL. This service is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not 
have to pay for the ambulance services coded A0427 for date of service June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454).  
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee is in a lot of pain and it is 
medically necessary for this procedure. The Plan denied your request. The Plan says the service requested does 
not meet the requirements for approval. 
 
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 a genicular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational therapy. It is the subject of ongoing clinical 
trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).