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

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on June 
26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, and continuing until the 
COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get up to eight free over-
the-counter tests for the month of April any time before April 30th and can then get another set of eight free 
over-the-counter tests during each subsequent calendar month through the end of the COVID-19 PHE. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on June 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission provided to the enrollee from February
24, 2023, to February 28, 2023.

You asked the Plan to pay for inpatient admission for the enrollee. The Plan denied dates of service February
24, 2023, to February 28, 2023, as the enrollee was safe for discharge as of February 23, 2023, and was waiting
skilled nursing facility (SNF) placement. Maximus upheld the Plan's denial; however, the incorrect dates of
service were referenced. The Plan requested a correction, and the case was reopened.

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. Our physician
reviewer found the enrollee was admitted with complaints of left knee and foot pain after a fall down a flight of
stairs. The enrollee was found to have fourth and fifth metatarsal fractures. The left leg was placed in a splint
and the enrollee was given instructions to be non-weight earing for 8 weeks. It is noted the enrollee refused
SNF placement and was discharged home with home health services to include physical therapy.

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 admission from February 24, 2023, to February 28, 2023, were not
met.

The records show the enrollee was stable for discharge on February 23, 2323. Continued inpatient care for
social issues or when awaiting placement to a lower level of care are not covered by Medicare as an inpatient
level of care was no longer required. Therefore, we decided that the Plan does not have to pay for inpatient
admission provided to the enrollee from February 24, 2023, to February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on June 27, 2023. 
 
You asked the Plan to pay for the drug test. 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 drug test provided on 
June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the walking boot provided on April 28, 
2023. 
 
You asked the Plan to pay for the office visit and the walking boot. 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 
walking boot provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network implantable loop monitoring 
provided on March 21, 2023, to June 05, 2023. 
 
You asked the Plan to waive the copayment for in-network implantable loop monitoring. You say that you did 
not see your provider on these dates, and do not understand why this is being billed. 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 $35 
copayment for physician/practitioner services, including doctors officevisits. 
 
You have been asked to pay a $35 copayment for in-network implantable loop monitoring. This item/service 
falls within the physician/practitioner services, including doctors officevisits 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. This is a charge for a heart monitor you 
have, as there are technologists who have to check the monitor. The total you owe is $70 ($35 copayment x 2 
visits = $70). Therefore, we decided that the Plan does not have to waive the copayment for in-network 
implantable loop monitoring provided on March 21, 2023, to June 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder (K0108). 
 
You asked the Plan to pre-approve a cup holder. You say that you are appealing on the grounds that Medicare 
has reviewed and approved the request and found the services to be medically necessary and covered. The Plan 
denied your request. The Plan says a cup holder does not serve a medical purpose and is 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 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 cup holder (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 22, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81328, 81335, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a combined cardio and pharmacogenomics test panel was provided. We looked at the file 
and Medicare rules. This NGS panel was not billed with a single code as required. Based on this information, 
we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on May 22, 2023, billed with codes 
81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81328, 81335, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the removal of impacted ear wax 
provided on June 05, 2023. 
 
You asked the Plan to pay for the office visit and the removal of impacted ear wax. 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 
removal of impacted ear wax provided on June 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) Tooth # 11 and 24 and using recognized assessment tools (D0602) provided on August 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial and would like the 
plan to reconsider. 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 Plans coverage rules apply in this case. This benefit includes the 
requested D0230 but is limited to two per one calendar year (Either D0220, D0230, D0270, D0272, D0273 or 
D0274 per one calendar year). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received intraoral - periapical first radiographic image (D0220) Tooth #8 and bitewings - four 
radiographic images (D0274) on date of service August 3, 2023. Although these are two different services, they 
fall within the same category in your Evidence of Coverage and are subject to the same frequency limitations. 
Therefore, this benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
intraoral - periapical each additional radiographic image (D0230) Tooth # 11 and 24 provided on August 3, 
2023. 
 
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. Using recognized assessment 
tools D0602 is not covered under the Plans dental benefits. 
 
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 using 
recognized assessment tools (D0602) provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for x-rays and the specialist office
visit provided on June 16, 2022.

You asked the Plan to waive this copayment. You say that you do not believe this cost share is correct. The
Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial stating a Plan contract had not been submitted for review. The Plan requested a reopen and noted the
required documentation was submitted.

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 a $35 copayment for x-rays and a $35 copayment
for each specialist visit. 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 copayments charged for x-rays and the specialist office visit
provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit (K0108). 
 
You asked the Plan to pre-approve a transit kit. You say that you would like the documentation provided to be 
reconsidered for the wheelchair and accessories that are medically necessary to meet the 
enrollee's current needs. The Plan denied your request. The Plan says this item is a convenience item and is not 
medically necessary. 
 
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 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. The item at issue 
in this appeal 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 a transit kit (K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the CT scan is medically necessary. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because it is 
not medically necessary for another CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the chest. Our reviewer 
says that the CT scan of the chest is not medically necessary. Our physician reviewer found given that the CT 
scan was to follow-up on tree and bud findings on a CT scan 1 year ago with no new symptoms or other 
suspicious findings, we agree that the CT scan is neither reasonable nor necessary. That said, should the 
enrollee have changes in symptoms then it would be warranted. 
 
  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 CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed or 
effective for the enrollee's skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize 
the target so as to minimize normal tissue dosing. Usually, IGRT is used when critical structures are abutting or 
in close proximity to the target that is being treated to high doses. This situation does not apply to this enrollee 
for which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. The device itself is Food and Drug Administration (FDA) 
approved for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but 
simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple 
simulations (77280) and/or IGRT for a technology for which need has not been established by published data 
or supported by consensus guidelines (many of which recommend against treatment with these devices in 
general) is not necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished 
in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT) (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a three wheeled walker with brakes. 
 
You asked the Plan to pre-approve a three wheeled walker with brakes. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the medical information received with the request does 
not indicate that the previous walker was lost, stolen, or irreparably damaged by a one-time event. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a three wheeled walker with brakes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0480 billed for date of service 
May 23, 2022. 
 
You asked the Plan to pay for procedure codes 80307 and G0480. You say that the services were billed 
correctly. The Plan denied your request. The Plan says the documentation does not include the method of 
testing. 
 
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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service.The CPT Code Manual 
definition of code G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify 
individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but 
not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding 
immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable 
isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, 
interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched 
quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or 
quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) 
if performed. 
 
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 procedure codes 80307 and G0480. Our reviewer says that 
procedure codes 80307 and G0480 are not supported. Our reviewer found the laboratory report does not 
include sufficient documentation to support method of testing. Therefore, these services cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 80307 and G0480 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 80307 and G0480 billed for date of service May 23, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on July 24, 2021. 
 
You asked the Plan to pay for the ambulance transport services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says a provider servicing a Plan member or other non-
contracted provider does have appeal rights on their own behalf if the provider agrees to sign the Waiver of 
Liability (WOL) form. We did not receive a completed WOL form; therefore we cannot review the non-
contracted providers representative request. 
 
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 ambulance transport services have 
been met. The Plan has provided evidence that several attempts were made to obtain the WOL from the 
provider but were not received. Therefore, we decided that the Plan does not have to pay for ambulance 
service, advanced life support and ground mileage provided on July 24, 2021.