Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.

You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration
because the services are medically necessary. The Plan denied your request. The Plan says 12 additional
physical therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 physical therapy visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found that the enrollee has had 14 sessions of physical therapy.
While the enrollee may continue to have some pain with a more strenuous activity such as lifting, they are
independent with mobility and preforming daily activities. Also, their motor strength and range of motion have
stayed the same. Therefore, the enrollee can manage their pain with a home exercise program and the services
of a skilled therapist are not needed for dynamic stretching or strengthening exercises.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for medical services provided on
October 4, 2022, October 20, 2022 and October 21, 2022.
You asked the Plan to waive this cost share . You say that you do not believe you had these medical services.
The Plan denied your request. The Plan says the medical records and the claim submitted by the provider show
these services were rendered. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional information.
The Plan is correct in this case. 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 for services rendered. The medical records confirm services were provided on
the dates of service in question.
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 share charged for medical services provided on October 4, 2022, October 20,
2022, and October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased on 
February 16, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider, without prior authorization.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, in this case the hearing aids 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261 x 2) purchased on February 16, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for presumptive drug testing (80307) provided on July 26, 2022. 
 
You asked the Plan to pay for presumptive drug testing. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says that this service is redundant 
and has already been billed/performed by the same or another provider for the same date of service. 
 
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 has provided no documentation or evidence to show that 
another code within the 80305-80307 code range was billed by any provider for this enrollee for this date of 
service. Without evidence that this service has been previously billed, we cannot verify that the service at issue 
is redundant. The Plan has not provided sufficient evidence to support their denial in this case. Therefore, we 
decided that the Plan has to pay for presumptive drug testing (80307) provided on July 26, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug infusion pump services, and the morphine sulfate 
injection provided on January 6, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the drug infusion pump services and the injection. You say that the services 
billed are supported in the records. The Plan denied your request. The Plan says enrollees must receive their 
care from a network provider. 
 
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 
items/services 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 drug infusion pump services, and the morphine 
sulfate injection provided on January 6, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 25, 2022, to 
December 23, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are appealing with supporting medical 
records. The Plan denied your request. The Plan says the enrollee received 150 days of inpatient hospital care 
during the benefit period; therefore, further inpatient hospital care is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient hospital care is covered up to 90 days 
per benefit period with a 60-day lifetime reserve.  

We looked at the file and Medicare rules. The enrollee received 150 days of covered inpatient hospital care 
from May 22, 2022, to November 25, 2022, which exhausted both the 90-day inpatient benefit as well as the 
60-day lifetime reserve benefit. Based on this information, we decided that Medicare rules for coverage of 
inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient 
hospital care provided from November 25, 2022, to December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 for date of service November 10, 
2022. 
 
You asked the Plan to pay for procedure code 64447. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code is not payable 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. 
 
In this case, the CPT Code Manual definition of code 64447 is injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve, including imaging guidance, when performed.  

We find that CPT code 64447 is not supported in the medical record. Specifically, this code was not billed with 
an anatomical modifier. This means the code is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64447 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64447 for date of service November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair component or accessory, not otherwise 
specified (K0108). 
 
You asked the Plan to pre-approve a privacy flap. You say that the requested component helps your back area 
and is needed. The Plan denied your request. The Plan says the records do not show that this wheelchair 
accessory is necessary for treatment of illness or injury, is used to 
serve a medical purpose, and is not primarily for convenience or comfort. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair component or accessory, not otherwise 
specified (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82947 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 82947. The Plan denied your request. The Plan says payment for 
code 82947 is bundled into payment for code 80048. 
 
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 82947 is a column II code to column I code 80048. Code 82947 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 82947 
billed for date of service July 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
August 2, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that the enrollee had a staged 
surgery. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are considered 
bundled and 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 procedure code. 
 
We find that procedure code 20930 and 20936 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 20930 and 20936 billed for date of service August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service November 
17, 2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this claim was coded accurately. The Plan 
denied your request. The Plan says this service is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was 
furnished to an enrollee in an office/non-hospital (Place of Service code 11) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on November 30, 2022, billed with 
code 87502. 
 
You asked the Plan to pay for the lab test as billed. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says code 87502 is not supported. The other billed codes have been approved.  
 
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 87502 is infectious agent detection by nucleic acid (DNA 
or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types. 
 
We find that CPT code 87502 is not supported in the medical record. Specifically, the lab report shows more 
than just two types or subtypes of influenza were tested. There is a more appropriate code for this service. 
Based on this information, we decided that Medicare rules for coverage of the lab test as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on November 30, 
2022, billed with code 87502.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210 x 6) provided on March 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial, you were told the 
provider was in-network with the Plan. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted.  

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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 15, 2022, when 
the Plan paid for D7140 x 2. Therefore, we decided that the Plan does not have to pay for the surgical 
extractions (D7210 x 6) provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (87631), 
infectious agent detection by nucleic acid (94761) and additional supplies (99072) provided on November 1, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. For code 94761, the records indicate procedure 94761 has a status 
indicator of T on the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule 
(NPFS) Relative Value (RVU) file. This means this service is always bundled into another payable physician 
service, 99406, billed the same day by the same provider. For code 99072, the records indicate that procedure 
99072, which has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into 
payment for other services not specified and no separate payment is made. 
 
For molecular diagnostic tests and other molecular pathology services administered through the Molecular 
Diagnostic Services (MolDX) Program, Medicare requires laboratories to apply for and obtain a test-specific 
identifier (a DEX Z-Code) that is unique to the laboratory's specific test. This identifier must be submitted as 
additional information at the time of claim submission and must be reported in conjunction with the appropriate 
Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS) code. 
 
We looked at the file and Medicare rules. 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 the 
infectious agent detection by nucleic acid (87631), infectious agent detection by nucleic acid (94761) and 
additional supplies (99072) provided on November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on August 26, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that the services should be covered. The Plan 
denied your request. The Plan says the infrared therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87150, 87481, 87653, and 87641 
billed for date of service November 9, 2022. 
 
You asked the Plan to pay for procedure codes 87798, 87150, 87481, 87653, and 87641. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87798, 87150, 
87481, 87653, 87801, 87641, and 87500 is bundled into payment for other codes. 
 
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 87798, is a column II code to column I codes 87150 and 87801. 
In this case, we have confirmed that code 87150 is a column II code to column I code 87500. 
In this case, we have confirmed that code 87481 is a column II code to column I codes 87150 and 87801. 
In this case, we have confirmed that code, 87653 is a column II code to column I codes 87150 and 87801. 
In this case, we have confirmed that code, 87641 is a column II code to column I codes 87150 and 87801. 
 
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 codes 87798, 87150, 87481, 87653, and 87641 billed for date of service November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service October 17, 2022, billed with code 99153.  

You asked the Plan to pay for procedure code 99153. You say that the sedation for this procedure should be 
covered.  The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service October 17, 2022, billed 
with code 99153.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from April 30, 2022, to May 7, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from April 30, 2022, to May 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services and custodial care.

You asked the Plan to pre-approve home health services and custodial care. You say that these home health services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health service. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have documented skilled therapy needs. The enrollee's needs appear to be custodial and long-term.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services and custodial care.