Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 1, 2023, to 
August 31, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all home health prospective payment system (PPS) 
claims must be submitted with Type of Bill (TOB) 0329. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB 
code. 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 the home health services rendered from 
August 1, 2023, to August 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for ambulance transport provided on
March 13, 2021.

You asked the Plan to waive this copayment. You say that you do not believe this copayment was charged
correctly. The Plan denied your request. The Plan says this copayment was charged correctly. The IRE upheld
the Plans decision. You requested an ALJ hearing on November 16, 2021. The ALJ sent a letter to you on
December 21, 2021, indicating the case was being remanded back to the IRE, however, the remand notice was
not actually received by the IRE until January 4, 2024.

After a reopen review of this appeal, we maintain that the documentation submitted in the case file 
was sufficient in content to make a substantive decision. The ALJ remanded the case back to us stating 
there was documentation not contained within the case file that they required for review. We have 
reopened the case and reviewed the original case file.

The documentation the ALJ claims is not available, specifically your appeal letter, was in the file, which was
the bill you submitted that you were receiving for the ambulance copayment. The Plan confirmed in the case
file that this submission was your appeal documentation. We will also note the ALJ has the right to reach out to
the health plan for additional information as well if they feel it necessary. Based on the information contained
in the case file, no further reconstruction of the record is needed.

Our decision remains unchanged. 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 $250 copayment for ambulance services. 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
charged for ambulance transport provided on March 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation - new or established 
patient (D0150), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each 
additional radiographic image (D0230) provided on September 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told by provider's office that you 
were not going to be charged for these x-rays. You also say that you would like this refunded to your 
allowance. The Plan denied your request. The Plan says your benefit for the requested services $1,275 dollar 
limit was met.  
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, certain limitations apply. The record 
shows your benefit for the dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $1,275 towards the cost of dental services provided in 2023. Therefore, we decided that the 
Plan does not have to pay more for the comprehensive oral evaluation - new or established patient (D0150), 
intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic 
image (D0230) provided on September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on July 10, 
2023. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement, subcutaneous tissue 
provided on September 27, 2023. 
 
You asked the Plan to waive the copayment for the debridement, subcutaneous tissue. You say that you cannot 
afford to pay the copayment for the surgery. 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $325 copayment for the debridement, subcutaneous tissue. This item/service 
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 the debridement, 
subcutaneous tissue provided on September 27, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (92507) provided on August 29, 2023 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a covered diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 92507 is a Group 1 code. Group 
1 codes are only covered when billed with a covered diagnosis code. 
 
We looked at the file and Medicare rules. Diagnosis codes R13.12, I69.354, & I50.9 are not listed as a covered 
diagnosis codes per the coverage article. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay 
for therapy services (92507) provided on August 29, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient psychiatric care provided from 
May 28, 2023, to June 6, 2023. 
 
You asked the Plan to waive the copayment for inpatient psychiatric care. You say that the Plan is breaking the 
law. 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 $750 
copayment for each inpatient psychiatric stay.  
 
You have been asked to pay $750 copayment for inpatient psychiatric care. This item/service falls within the 
Inpatient Services in a Psychiatric Hospital 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 psychiatric care provided from May 28, 2023, to June 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 17, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo System. 
 
You asked the Plan to pre-approve the Barostim Neo System. You say that the Barostim Neo System is 
medically necessary. The Plan denied your request. The Plan says the Barostim Neo System is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Barostim Neo System. Our reviewer 
says that the requested Barostim Neo System is not considered medically reasonable and necessary. Our 
physician reviewer found that Baroreflex stimulation devices have been considered potential alternative 
treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse 
generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one 
of the carotid arteries. In August 2019 the Food and Drug Administration (FDA) approved the system for use in 
patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, 
and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement 
in normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not 
be considered medically reasonable and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Barostim Neo System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis (27279) of the sacroiliac joint. 
 
You asked the Plan to pre-approve the arthrodesis. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the arthrodesis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, 
less invasive conservative care measures is not evident. There is no documentation of a trial and failure of 
sacroiliac joint injections, with at least 75% reduction of pain. The recent exam does not corroborate objective 
deficits consistent with sacroiliac joint pain and an absence of other plausible sources of pain. The exam did not 
corroborate positive sacroiliac provocative exam findings. Moreover, there are no diagnostic imaging studies 
provided to corroborate sacroiliac joint pathology, ipsilateral hip radiographs to rule out osteoarthritis, and/or 
lumbar imaging to rule out other causes of the low back/buttock pain. 
 
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 arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an arthrodesis (27279) of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toilet rail grab bar. 
 
You asked the Plan to pre-approve these services. You say that you need help getting up due to your knees and 
hips. The Plan denied your request. The Plan says the item is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar 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 toilet rail grab bar.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services rendered on August 30, 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 the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until August 31, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for emergency room services rendered on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the residence visit provided on June 28, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the residence visit. You say that the provider is a hospitalist physician and was 
not responsible for requesting the authorization. The Plan denied your request. The Plan says that their original 
decision to deny payment was correct. 
 
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 residence visit provided on June 28, 2023, by 
an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray (73502) provided to the enrollee on July 25,
2022.

You asked the Plan to pay for the hip x-ray. You say that the claim should be paid. The Plan denied your
request. The Plan says Original Medicare is responsible for payment. Maximus overturned the Plan's denial.
The Plan requested a reopening and stated that the enrollee had hospice benefits on this date of service. The
Plan is correct in this case. Medicare rules say that Original Medicare, not the Plan, is responsible for all
Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the
first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare
Hospice benefits on July 23, 2022. The services in question were provided before the end of that month.
Therefore, we decided that the Plan does not have to pay for the hip x-ray (73502) provided to the enrollee on
July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88344 billed for date of service January 
25, 2023. 
 You asked the Plan to pay for procedure code(s) 88344. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88344. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88344. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88344 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88344 billed for date of service January 25, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of pacemaker (33208) provided on July 7, 2023. 
 
You asked the Plan to pay for insertion of pacemaker. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of insertion of pacemaker have not been met. Specifically, this claim was billed with the office POS 
code. The records do not support that the service at issue was provided in an office setting. Therefore, we 
decided that the Plan does not have to pay for insertion of pacemaker (33208) provided on July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 07, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on July 07, 2023.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for diagnosis code E43. We decided that the Plan does not have to pay for 
diagnosis code Z68.1.  
 
You asked the Plan to pay for inpatient hospital services provided on January 8, 2023, to January 11, 2023, at 
the Diagnosis Related Group (DRG) originally billed. You say that the claim was accurately billed with the 
appropriate DRG. The Plan says that the medical records did not have sufficient documentation to clinically 
validate the diagnosis of E43 (unspecified severe protein-calorie malnutrition) and Z68.1 (body mass index 
[BMI] 19.9 or less, adult). 
 
We decided that the Plan has to pay for diagnosis code Z68.1.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with Z68.1 defined as body mass index [BMI] 19.9 or 
less, adult. 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 inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the patient had documented weight of 135lb and 
height of 5'11", therefore diagnosis code Z68.1 is justified as BMI is 19. However, there is insufficient 
documentation to support diagnosis code E43. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the claim billed with Z68.1. Therefore, we decided that the Plan has to pay for 
diagnosis code Z68.1.  
 
We also decided that the Plan does not have to pay for E43. 
 
As noted above, our reviewer found that the diagnosis code E43 is not supported. Therefore, we decided that 
the Plan does not have to pay for diagnosis code E43. 
 
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.