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

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
February 14, 2023. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you were not given 
a choice, you were picked up by the ambulance and taken to the hospital. 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 $315 
copayment for ambulance services. 
 
You have been asked to pay a $315 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance services 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. However, since the allowed amount is less than the standard copayment, you only owe 
$304.69. Therefore, we decided that the Plan does not have to waive the copayment for an in-network 
ambulance ride provided on February 14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837). provided on July 14, 2023. 
 
You asked the Plan to pay for psychotherapy services (90837).. You say that the services at issue were a 
medical necessity for the enrollee. 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 psychotherapy services 
(90837). provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a bilateral sacroiliac joint injection. We decided that the Plan does 
not have to pre-approve a sacroiliac joint injection on the left side.  
 
You asked the Plan to pre-approve a bilateral sacroiliac joint injection. The Plan says that sacroiliac joint 
injections are not medically necessary. 
 
We decided that the Plan has to pre-approve a sacroiliac joint injection for the right side and does not 
have to pre-approve a sacroiliac joint injection on the left side.  
 
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 bilateral injection. Our reviewer 
says that the sacroiliac joint injection on the right is medically necessary. Our physician reviewer found that 
there is documentation of positive FABER, SI compression, thigh thrust, and straight leg raise tests on the right 
side where the enrollee's pain is most severe. The enrollee's pain has been present for over three months and 
there appears to be multiple pain generators which may require treatment. However, there is no documentation 
of positive provocative maneuvers at the left sacroiliac joint and the pain is much more significant on the right 
side than the left. Also, there is insufficient evidence to suggest left-sided sacroiliac joint dysfunction as a 
significant pain generator. Additionally, injection of both joints in the absence of such evidence would not 
provide appropriate diagnostic information regarding the source of the enrollees back pain. Therefore, a 
steroid injection to the right SI joint is medically necessary and the left SI joint injection is not appropriate. 
 
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 right SI joint has been met. Therefore, we decided that the Plan does has to 
pre-approve a sacroiliac joint injection for the right side and does not have to pre-approve a sacroiliac joint 
injection on the left side. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast cancer index (81518) provided April 5, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please waive any timely filing on this appeal 
due to the COVID-19 pandemic situation which has not been easy on any provider. The Plan denied your 
request. The Plan says the claim was received after the timely filing limitation. 
 
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 genetic testing was not filed until April 17, 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 the breast cancer index (81518) provided April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial The 
Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 21, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you do not 
believe you should be responsible for this charge since the ambulance driver said it was not necessary to go to 
the hospital. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 82306) rendered on 
March 30, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a 
benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that laboratory services (vitamin D testing) were rendered on March 30, 2023 and are being requested for 
coverage. However, the patient did not have a listed diagnosis such as vitamin D deficiency or supplementation 
for such, osteoporosis, or other related condition that would warrant this vitamin testing. Therefore, the vitamin 
D test will be considered not medically necessary 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 82306) rendered on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit, and an outpatient clinic visit 
provided on May 4, 2023. 
 
You asked the Plan to waive the cost share for an office visit, and an outpatient clinic visit. You say that you 
disagree with the cost share. 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 $60 
copayment for out-of-network office visits. Your contract with the Plan also clearly says that you must pay 
40% coinsurance for out-of-network outpatient hospital visits. 
 
You have been asked to pay a $60 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay $49.65, which is 40% coinsurance of the allowed amount for the outpatient clinic visit ($124.13 allowed 
amount x 40% = $49.65). This item/service falls within the outpatient surgery, including services provided at 
hospital outpatient facilities benefit category. You have been asked to pay a total of $109.65 ($60 copayment + 
$49.65 coinsurance = $109.65). This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the cost share for an office visit, and an 
outpatient clinic visit provided on May 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on May 
01, 2023, to May 19, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you say that you do not 
know what this claim if for. 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 $196 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $196 copayment for skilled nursing facility. This item/service falls within the Skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. You have been asked to pay a total of $2,352 for the skilled nursing facility care 
($196 copayment x 12 days = $2.352). Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility provided on May 01, 2023, to May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lesion destruction procedure and an office visit provided 
on May 25, 2023. 
 
You asked the Plan to pay for the lesion destruction procedure and an office visit. You say that you are 
requesting reconsideration of the denied claim. 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 lesion destruction 
procedure and an office visit provided on May 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation services received on 
January 4, 2023, to March 1, 2023. 
 
You asked the Plan to pay for the non-emergency transportation services. You say that the transportation 
services were medically necessary for you to get to your appointments. The Plan denied your request. The Plan 
says you did not meet the criteria for coverage for non-emergency transport services. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the non-emergency transportation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the non-emergency transportation services 
received on January 4, 2023, to March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 26, 
2023, and May 18, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for nursing facility care. You say that the enrollee was residing in a nursing facility 
when the services were provided and could not choose an in-network provider. The Plan denied your request. 
The Plan says the 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 subsequent nursing facility care provided on 
January 26, 2023, and May 18, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cystourethroscopy procedure provided 
on April 06, 2023. 
 
You asked the Plan to reduce the copayment for a cystourethroscopy procedure. You say that the enrollee was 
always charged a lower 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 $250 
copayment for outpatient surgery in an ambulatory surgery center. 
 
You have been asked to pay a $250 copayment for a cystourethroscopy procedure. This item/service falls 
within the outpatient surgery in an ambulatory surgery center 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 reduce the copayment for a cystourethroscopy procedure provided on April 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the injection provided on July 01, 2023. 
 
You asked the Plan to pay for the office visit and the injection. You say that you are requesting reconsideration 
of the denied claim. 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 office visit and the 
injection provided on July 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 99100 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99100 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99100 billed for date of service May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided to the enrollee from December 12, 2022, to December 29, 2022.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the enrollee exhausted this benefit prior to December 12, 2022, and the
services were not supervised by a physician or required practitioner. Maximus overturned the Plans denial. The
Plan requested a reopen and stated Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that acupuncture services
are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers
limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-
day period, and no more than 20 sessions per year. The Plan offers coverage beyond the Medicare acupuncture
benefit. As such, the Plan's rules apply in this case. The Plans coverage criteria were not met. The records
show the services provided exceeded the number of sessions covered in a 90-day period and were not
supervised or overseen by a physician, or licensed practitioner as required by the Plan contract. We looked at
the file and Medicare rules. Based on this information, we decided that the rules for coverage of the
acupuncture services provided were not met. Therefore, we decided that the Plan does not have to pay for
acupuncture services provided to the enrollee from December 12, 2022, to December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes U0005, 87500, 87641, 87631, and 87798 
billed for date of service January 6, 2023. 
 
You asked the Plan to pay for procedure codes U0005, 87500, 87641, 87631, and 87798. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the codes are not supported. 
 
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 codes 
87641, 87631, and 87798 are column II code to column I code 87801. The -59 modifier is not supported as a 
separate and distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been 
met.  
 
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 U0005 is infectious agent detection by nucleic acid (dna 
or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), 
amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 
calendar days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004) 
as described by cms-2020-01-r2. The definition of code 87500 is infectious agent detection by nucleic acid 
(DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT codes U0005 and 87500 are not supported in the medical record. Specifically, U0005 is an 
add-on code that was not billed with a required primary procedure code. The file shows that a panel of testing 
was performed and there is a more appropriate code than 87500. 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 procedure codes U0005, 87500, 87641, 87631, 
and 87798 billed for date of service January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on April 4, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on April 4, 2023.