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

 
We decided that the Plan has to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81240, 81241). 
 
You asked the Plan to pre-approve F2 and F5 gene analysis. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures are covered when 
certain 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 F2 and F5 gene analysis. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the review indicates that the 
enrollee is a 46-year-old male with a deep vein thrombosis (DVT) and a pulmonary embolism. The review has 
determined that the enrollee meets 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 F2 and F5 gene analysis have been met. Therefore, we decided that the Plan has 
to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 
20210G>A variant and F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden 
variant (81240, 81241).  
 
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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 00600-QK. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100-GY.  
 
You asked the Plan to pay for practitioner services provided on July 10, 2023, billed with procedure codes 
99100-GY and 00600-QK. You say that the claim is billed correctly and should be paid. The Plan says that 
code 99100-GY is considered bundled and is not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 00600-QK.  
 
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) 00600-QK.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100-GY. 
 
The Plan follows Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator B means 
that payment for covered services is always bundled into payment for other services not specified. There will 
be no payment amounts for these codes and no separate payment is ever made. 
 
We looked at the file, and Medicare rules. We have confirmed that code 99100-GY has a Status indicator B and 
is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
services described by procedure code(s) 99100-GY have not been met. Therefore, we decided that the Plan 
does not have to pay for the services described by procedure code(s) 99100-GY. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of neurostimulator electrode array; 
sacral nerve (64581). 
 
You asked the Plan to pre-approve open implantation of neurostimulator electrode array; sacral nerve. You say 
that this is medically necessary. The Plan denied your request. The Plan says this 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 open implantation of neurostimulator 
electrode array; sacral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the records in this case do not document 
trial and failure of all pharmacologic and non-invasive treatments for the patient's condition including bulking 
agents such as psyllium or methylcellulose. Records do not show trial and failure of bismuth subsalicylate. 
Records do not show trial and failure of biofeedback as is recommended in the peer-reviewed medical 
literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open implantation of neurostimulator electrode array; sacral nerve have not 
been met. Therefore, we decided that the Plan does not have to pre-approve open implantation of 
neurostimulator electrode array; sacral nerve (64581).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided on 
July 5, 2023. 
 
You asked the Plan to pay for D2740 and D2950. You say that you needed this dental work. The Plan denied 
your request. The Plan says the rendered dental services are not covered 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. 
 
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 a crown 
(D2740) and a core build-up (D2950) provided on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 13, 
2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $20 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $20 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on July 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 24, 2023 to 
March 25, 2023. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. .  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 24, 2023. The NOA was not received by the Plan until May 08, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on February 24, 2023 to March 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 12, 2023, to July 19, 
2023. 
 
You asked the Plan to pay for chiropractic services. You say that you do not understand why the services were 
not covered. 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 chiropractic services 
provided on July 12, 2023, to July 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment from December 7, 2023-
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of December 7, 2023 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment from December 7, 2023-forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 22, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58761, this type of testing must be billed with a single unit of service of a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on July 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you cannot utilize your hands to move 
around with your manual wheelchair. You also say that your personal care attendant only assists you for two 
hours in the morning, and two hours in the evening, and the rest of the day you are bed bound. The Plan denied 
your request. The Plan says there is no evidence that a power wheelchair is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our physician 
reviewer found the documentation available for review does not support that you require a power mobility 
device to accomplish mobility related self-care tasks in the home. There is no indication you are unable to use 
an alternative assistive device. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to provide continued skilled nursing facility (SNF) care beyond May 5,
2023.

You asked the Plan to provide continued SNF care. You say that at the time of the appeal, continued SNF care
was medically necessary. The Plan denied your request. The Plan says at the time of the appeal, the Medicare
criteria for continued care were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria. The Plan noted the medical records show as of May
5, 2023, you were moderate to maximum assist on all activities and still required help to walk short distances
after 72 days of daily skilled services.

The Plan is correct in this case. 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.
Based on the medical records provided, as of May 5, 2023, your care was custodial in nature which is not
covered Medicare. Therefore, we decided that the Plan does not have to provide continued skilled nursing
facility (SNF) care beyond May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 10, 2023, and billed 
with codes 87653, 87640, 87481, 87798 and 87641. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on July 10, 2023, and billed with codes 87653, 
87640, 87481, 87798 and 87641.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 96327 billed for date of service February 14, 2023.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. the
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that
this claim denied because this service was billed with an inappropriate diagnosis code. The diagnosis code
billed is not allowed as a primary diagnosis. The ICD Official Coding Guidelines, Chapter 21, states that
influencing health status and contact with health services (Z00-Z99) explains that these codes just indicate
circumstance which influence an individual's health status but not a current illness or injury. Also, according to
ICD-10 CM Guidelines, Chapter 21, Section 16, only certain Z Codes can be first listed or as primary, and
Z79.890 is not in that list.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim was reported with an invalid diagnosis code. Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
code 96327 billed for date of service February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of code Q9966 provided on June 19, 2023. 
 
You asked the Plan to pay for two units of code Q9966. The Plan denied your request. The Plan says the billed 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 two units of code Q9966 Our reviewer says 
that the records provided do not support two units of code Q9966. Our physician reviewer found that the 
procedure report documents "Then using fluoroscopic guidance in the lateral view, a 25 gauge, 1.5" needle was 
advanced intra-articularly and 0.5cc of contrast agent was injected confirming intra-articular needle 
placement". In this case, contrast and the units billed cannot be verified, as the record includes insufficient 
documentation to verify the services provided.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two units of code Q9966 have not been met. Therefore, we decided that the Plan 
does not have to pay for two units of code Q9966 provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 3, 2023, billed with 
procedure codes 00811-QZ-P3-77 and 99100-77. 
 
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 code 00811-QZ-
P3-77 and code 99100-77 is 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 CPT code. The rules also say that the Physician Fee 
Schedule Status Indicator B means that payment for covered services is always bundled into payment for other 
services not specified.  
 
In this case, the CPT Code Manual definition of code 00811 is anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified. 
 
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 the medical record does 
not include sufficient documentation to verify appropriate coding. The record includes a procedure report 
which documents "colonoscopy" and a pre-operative evaluation and management service. Therefore, the 
procedure code and appended modifiers cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. We have confirmed that code 99100-77 has a 
status indicator B and is not separately payable. 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 March 3, 2023, billed with procedure codes 00811-QZ-P3-77 
and 99100-77.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided July 
26, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you have attached the 
supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says under 
Medicare, the request 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 looked at the file, and Medicare rules. The record does not show a diagnosis of psoriasis or a history of 
psoriasis. There are also no other factors described that would justify treatment at home rather than alternative 
sites, like a clinic or the hospital. Based on this information, we decided that Medicare rules for coverage of the 
ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultraviolet light therapy system (E0691) provided July 26, 2023.