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

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
26, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have for reimbursement for computed tomography (CT) guided bone 
marrow biopsy provided on June 16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan for reimbursement for the outpatient procedure. You say that you do not believe the Plan 
offers this procedure and therefore it should be covered. You have had other procedures not offered by the Plan 
reimbursed recently. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has for reimbursement 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 for reimbursement for these 
items/services. Therefore, we decided that the Plan does not have for reimbursement for computed tomography 
(CT) guided bone marrow biopsy provided on June 16, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the nerve stimulator. You say that this procedure is necessary due to the 
failure of conservative treatments to address pain and restore function. The Plan denied your request. The Plan 
says 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 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 nerve stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Sprint peripheral nerve stimulator is considered experimental/investigational 
and is not medically necessary for the treatment of chronic 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 nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulator.
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 the IRF services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements 
for approval.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found while the medical record supports a need for 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 
there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic hand surgery to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve orthopedic hand surgery to be provided by the requested out-of-network 
provider. You say that you have seen this provider for at least 10 years and you have had previous surgery with 
this provider. You say that finding a new doctor makes you uneasy as you have had past trauma that is 
triggered when you have to get a new doctor that is male. The Plan denied your request. The Plan says you or 
your physician have not provided clinical information to indicate the services that you are requesting cannot be 
provided by an in-network provider. The Plan says that although orthopedic hand surgery services are available 
to you, these services can be received from providers in the Plans network  
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic hand surgery to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression cooling device (E1399) provided 
on June 20, 2023. 
 
You asked the Plan to pay for a pneumatic compression cooling device. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the item obtained was rendered by a provider who is not 
under contract with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a pneumatic compression cooling device 
(E1399) provided on June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for electronic connection (E2311), harness
(E2313), expandable controller (E2377), positioning belt/safety belt/pelvic strap (E0978), and hand or chin
control interface (E2374) for the enrollee.

You asked the Plan to provide coverage for these accessories. You say that these accessories are medically
necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus
partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan notes that toggle switches come included with the approved power option(s) and
power feature(s). The enrollees' medical records show the enrollee has 3/5 bilateral arm strength to
independently self-feed, groom and do hygiene. This would also mean the enrollee has adequate strength to
push a switch, which is like pushing a button. Therefore, the upgraded electronics exceed the enrollee's needs.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered.

The available clinical documentation in the case file does not support that the requested expandable controller,
harness, and electronic connection were medically reasonable and necessary for the enrollee in this case. The
notes do not show the medical necessity of controlling the power options through means other than the
switches already approved. Therefore, we decided that the Plan does not have to provide coverage for an
electronic connection (E2311), harness (E2313), expandable controller (E2377), positioning belt/safety
belt/pelvic strap (E0978), and hand or chin control interface (E2374) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service May 23, 
2023.   
You asked the Plan to pay for procedure code 88377. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on June 2, 2023. 
 
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 there is a more appropriate lab panel code that should have been used. 
 
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 codes 81225, 81226, 81240, 81241, and 81328 are not supported in the medical record. Specifically, one code should have been used for these services. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services rendered on June 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intrarosa. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Intrarosa.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87500, 87563, 87640, 87641, 
87653, 87798) provided on June 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798 are not supported in the 
medical record. Specifically, the records do not include a physician order for the tests billed. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87481, 87491, 87500, 87563, 87640, 87641, 87653, 
87798) provided on June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on August 17, 
2023. 
 
You asked the Plan to pay for Guardant Reveal testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant Reveal testing (81479) provided on August 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76857 billed for date of service June 30, 
2023. 
 You asked the Plan to pay for procedure code 76857. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76857 is bundled into payment for code 76856. 
 
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 76857 
is a column II code to column I code 76856. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76857 billed for date of service June 30, 2023.
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 the enrollee needs IRF services as he has a high risk 
for falls and sustaining injury to falls. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for an IRF admission.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 15, 2023, to 
March 6, 2023. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Specifically, the claim 
was billed with an admission date of November 16, 2022, but the NOA was billed with a date of February 15, 
2023. Based on this information, we find that the Medicare rules for payment of the claim at issue have not 
been met. Therefore, we decided that the Plan does not have to pay for home health services provided from 
February 15, 2023, to March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation 
submitted did not include documentation to determine a relationship between the ordering provider and the 
patient at the time of 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 the services have been met. The 
documentation submitted by the non-contract provider did not contain medical records for the date of service in 
question. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on 
May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient currently meets acute long 
term acute care admission criteria. The Plan denied your request. The Plan says the patient is receiving 
appropriate inpatient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is receiving appropriate care in the current acute care setting as provided 
by the Health Plan. Our reviewer also found that the documentation does not support that LTACH services are 
medically appropriate at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unoccupied transit kit (A9270) and incontinence seat 
cushion (K0108). 
 
You asked the Plan to pre-approve an unoccupied transit kit and incontinence seat cushion. You say that 
Medicare has already approved this request. The Plan denied your request. The Plan says a transit kit and 
incontinence seat cushion do not primarily serve medical functions and therefore are not considered durable 
medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also state that for equipment to be covered, it must be appropriate and needed for 
use inside the home.  
 
The items at issue in this appeal does not serve purposes that are primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. An unoccupied 
transit kit is also for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve 
an unoccupied transit kit (A9270) and incontinence seat cushion (K0108).