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

 
We decided that the Plan does not have to pay for code G0483 for date of service May 8, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the plan's denial. The Plan denied 
your request. The Plan says the services billed 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, the CPT Code Manual definition of code G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation shows 
that less than 22 drug classes were tested. This means there is a more appropriate code to be billed for the 
services rendered. Based on this information, we decided that Medicare rules for coverage of code G0483 have 
not been met. Therefore, we decided that the Plan does not have to pay for code G0483 for date of service May 
8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service June 10, 
2022, to July 6, 2022. You asked the Plan to pay for the billed services. You say that a late NOA does not result in unpaid claims. The 
Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 11, 2022. A valid NOA was not received by the Plan until October 6, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service June 10, 2022, to July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LUCI system for a power wheelchair. 
 
You asked the Plan to pre-approve LUCI system. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has the ability to safely operate the power wheelchair and participate in 
mobility-related activities of daily living in the home. 
 
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 LUCI system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found records from the treating physician make no mention of the necessity of the LUCI system or 
any other special needs the enrollee has with regard to vision and safe operation of the power wheelchair. 
Overall, it is not clear that the LUCI system is not primarily for use outside the home as opposed to assisting with participation in mobility related activities of daily living such as toileting, feeding, grooming, and bathing 
in customary locations within the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LUCI system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the LUCI system for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on March 
30, 2023, to April 18, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the requested device is not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on March 30, 2023, to April 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs received on June 6, 2023, to June 7, 2023.

You asked the Plan to pay for the self-administered drugs. You say that you disagree with the Plan's denial. 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 pay for the self-administered drugs received on June 6, 2023, to June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87500 billed for date of service 
May 31, 2023. 
 
You asked the Plan to pay for procedure codes 87150 and 87500. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support code 87500. 
Payment for code 87150 is bundled into code 87500. 
 
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 87500 is: Infectious agent detection by nucleic acid 
(DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We have also confirmed that code 87150 is a column II code to column I code 87500; however, 87150 was 
billed with a modifier.  
 
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 87150 and 87500. Our reviewer says that 
procedure codes 87150 and 87500 do not meet criteria for payment. Our reviewer found that regarding code 
87500, the provided laboratory report supports multiple infectious agent detection by nucleic acid, amplified 
probe technique. In this case, a more specific panel code than code 87500 would be reported for the service 
provided. Regarding code 87150, you reported the procedure code with appended modifier XU to indicate an 
unusual non-overlapping service to bypass the edit with code 87500. However, the laboratory report does not 
include sufficient documentation to verify a rationale to support an unusual non-overlapping service. 
 
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 87150 and 87500 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87150 and 87500 billed for date of service May 31, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a crown and core buildup for tooth number 20 for
the enrollee.

You asked the Plan to provide coverage for these dental services. The Plan denied your request. The Plan says
the dental records do not show the enrollee met the criteria required for these services. Maximus overturned the
Plans denial due to a lack of dental x-rays in the file. The Plan requested a reopen and submitted the required
dental x-rays. The Plan noted crowns are covered by this Plan if the bone holding in the tooth is healthy and
stable. The records submitted do not show enough healthy bone around tooth 20 to support this request.

The Plan is correct in this case. Medicare generally does not cover dental services. The Plan offers a dental
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers medically necessary and reasonable dental services. Based on the dental x-rays provided, the enrollee
does not show enough healthy bone around tooth 20 to support the requested crown. Therefore, we decided that
the Plan does not have to provide coverage for a crown and core buildup for tooth number 20 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on July 14, 2023.

You asked the Plan to pay for D3331. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says you would like the Plan to pay for this.

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, 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 the treatment of root canal obstruction (D3331) provided on July 14, 2023. 

The original decision letter was amended to include specific details about Medicare rules which were omitted in error.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service July 10, 
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 July 10, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer.  
You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Infed (iron dextran) and Venofer (iron sucrose). The documentation does not support that Infed (iron 
dextran) and Venofer (iron sucrose) would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 provided on December 6, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 5 units of CPT code 87481 are not supported in the medical record. The medical record only 
supports 4 units of CPT code 87481. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87481 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87481 provided on December 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 18, 2023, to 
June 16, 2023. 
 
You asked the Plan to pay for the home health services as billed. 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 as required. 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 
the home health services provided from May 18, 2023, to June 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics (PGx) testing rendered on May 9, 
2023.  
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PGx testing is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee had a diagnosis of muscle 
wasting and atrophy, not elsewhere classified, unspecified site. The records do not contain clinical 
documentation demonstrating that medications being considered for use, or being used, for this enrollee are 
known to have gene-drug interaction(s) that have been demonstrated to be clinically actionable as defined by 
the Food and Drug Administration (FDA) or Clinical Pharmacogenetic Implementation Consortium guidelines. 
The records do not support that the criteria for coverage were met and that the testing was medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 the pharmacogenetics (PGx) testing rendered on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 provided on May 4, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, medical records submitted 
do not include an order that specifically list what test(s) are to be performed in the custom panel. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0483 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0483 provided on May 4, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided June 
6, 2023. 
 
You asked the Plan to pay for the psychiatric services. You say that you would appreciate it very much for 
reconsideration of the denial. The Plan denied your request. The Plan says the services was rendered by a 
provider who is not eligible to participate with 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 the psychiatric diagnostic evaluation 
(90791) provided June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heat and massage lift recliner provided on March 14, 
2023. 
 
You asked the Plan to pay for the heat and massage lift recliner. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in 
the Medicare program. 
 
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 the heat and massage lift recliner 
provided on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99213) 
rendered on May 17, 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 the documentation supports straightforward medical decision making. 
 
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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation only supports 
straightforward decision making, with no documentation showing that 20-29 minutes of total time was spent on 
the date of the encounter. 
 
We looked at this coder'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 evaluation and management services (procedure code 99213) rendered on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2023, billed with 
code 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel 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 
March 15, 2023, billed with code 81345.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E0466 ventilator for the enrollee.

You asked the Plan to provide coverage for this equipment. The Plan denied your request. The Plan says the
Medicare coverage criteria were not met. Maximus overturned the Plans denial for a lack of medical records in
the file. The Plan requested a reopen and provided the required records.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of ventilators. The documentation is insufficient to support that a home ventilator (E0466) is
medically reasonable and necessary in this case. Products classified as HCPCS code E0466, when used to
provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical
condition, shall not be paid in the FSS payment category.

A ventilator is not eligible for reimbursement for any of the conditions described even though the ventilator
equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Requests for
ventilators used to provide CPAP or bi-level CPAP will be denied as not reasonable and necessary. Therefore,
we decided that the Plan does not have to provide coverage for an E0466 ventilator for the enrollee.