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

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 23, 
2023.  
 
You asked the Plan to pay for procedure code 99285. You say that emergency room and inpatient visits are 
billable on the same day. The Plan denied your request. The Plan says payment for code 99285 is bundled into 
payment for code 99233. 
 
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 99285 is a column II code to column I code 99233 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 99285 
billed for date of service January 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician supervision 
(G0277, 99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy with physician supervision. You say that this is 
medically necessary. The Plan denied your request. The Plan says records do not show that the enrollee has 
osteoradionecrosis, or any other covered indication. Hyperbaric oxygen therapy as a preventative service is not 
covered by Medicare. 
 
The Plan follows Medicare rules. 
 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 hyperbaric oxygen therapy with 
physician supervision. Our reviewer says that the enrollee does not meet coverage criteria for the requested 
service. Our physician reviewer found it is not standard of care to start hyperbaric oxygen therapy as a 
preventative measure before dental procedures, and not medically 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 hyperbaric oxygen therapy with physician supervision have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician 
supervision (G0277, 99183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 provided on February 16, 2023. 
 
You asked the Plan to pay for procedure code 87086. 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 that urine culture services are coverable when 
billed with a covered diagnosis code. You billed the urine culture service in dispute with diagnosis code C61. 
Diagnosis code C61 is not listed in the controlling Medicare policy as a covered diagnosis for this service. 
Based on this information, we decided that Medicare rules for coverage of code 87086 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87086 provided on February 16, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 3, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests are separately 
billable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee from October 23, 2022, to November 8, 2022, under claim number.
You asked the Plan to pay for the acute inpatient hospital care. You say that these services were medically necessary while the enrollee was out of the country. The Plan denied your request. The Plan says that services were paid at the Medicare allowable rate that would be covered by Original Medicare. Maximus overturned the Plans denial based on medical necessity. The Plan requested a reopen and provided the claim and the Explanation of Benefits explaining how the services were paid.
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. The enrollee's contract with the Plan clearly says the Plan will only pay for services provided out of the country at the Original Medicare rate. Review of the Explanation of Benefits shows the Plan paid those codes that were allowed by Medicare at the Medicare allowable rate, as they would have if the provider had been in the United States. As Medicare does not cover services provided out of the country, this payment by the Plan is a supplemental benefit and subject to the Plan's rules for claim submission. It should also be noted the Plan is unable to compel providers to submit the Medicare standard codes that would be expected from providers in the United States. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee from October 23, 2022, to November 8, 2022, under claim number.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0396 billed for date of service March 16, 
2023. 
 You asked the Plan to pay for procedure code G0396. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code G0396 is bundled into payment for code 99214. 
 
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 G0396 
is a column II code to column I code 99214. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0396 billed for date of service March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve a continuation of care with an OON provider . You say that you have been 
seeing the requested OON provider for 16-years. You say that this OON provider is the world's leading 
specialist on Coccidioidomycosis and that you trust his judgement.  The Plan denied your request. The Plan 
says you can see an in-network provider for care.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for OON coverage have not been met.  Our physician reviewer 
found the denial is medically justified as disseminated Coccidioidomycosis 16-years after the fact is expected 
to be manageable by a board-certified infectious diseases doctor such as the network provider the Plan has 
referred you to. There is no documentation to support a unique feature to your condition to preclude this 
referral as unsafe. The Plan has shown that they have in-network providers who meet standard of care for your 
condition. 
 
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 continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0481 for date of service October 4, 2022. 
 
You asked the Plan to pay for code G0481. 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 G0481 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; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation shows 
that more than 14 drug classes were tested. This means code G0481 is not supported. Based on this 
information, we decided that Medicare rules for coverage of code G0481 have not been met. Therefore, we 
decided that the Plan does not have to pay for code G0481 for date of service October 4, 2022.
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 March 21, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
911 for elevated blood pressure and upon arrival of the emergency medical technician you felt better so you 
declined the service. 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 March 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 March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for progressive lenses (V2781) and ultra-violet lenses (V2755). 
 
You asked the Plan to pay for progressive lenses (V2781), ultra-violet lenses (V2755). You say that you were 
unaware the lens would not be covered. You also say that your benefits do not clarify on the eyeglass purchase. 
The Plan denied your request. The Plan says that this is not a covered benefit on your plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a $125 combined credit every year for all additional eyewear. The Plan rules 
also say that the coverage is limited to one pair of eyeglasses (lenses and frames) every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers up to a $125 combined credit 
every year for all additional eyewear. The Plan contract also says that the coverage is limited to one pair of 
eyeglasses (lenses and frames) every year. The EOC does not state any limitations to the lenses or any 
upgrades. The EOC merely states that the Plan covers lenses. Based on this information, we decided that the 
Plan's rules for coverage of progressive lenses (V2781), ultra-violet lenses (V2755), tinting (V2745) ad frames 
(V2020) have been met. Therefore, we decided that the Plan has to pay for progressive lenses (V2781) and 
ultra-violet lenses (V2755).  
 
  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 procedure code 37223 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says an appropriate primary procedure code was not 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, we have confirmed that code 37233 is an add-on code that has not been billed with an appropriate 
primary procedure code. 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 37223 billed for date of service August 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria. You also 
say the enrollee is not medically or functionally safe to return home and the services they require cannot be met 
at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for services in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
December 20, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the provider does not have the capacity to bill directly 
for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that since this provider is not certified for Medicare 
participation they are not eligible for payment..  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the subsequent nursing facility care have not been met. Therefore, we decided that the Plan does 
not have to pay for the subsequent nursing facility care services provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on May 25, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the documentation requirements have not been met. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid physician order, proof of delivery and relevant medical records which support medical necessity. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The medical records submitted do not discuss the need for an electrical stimulator, how it intended to be used or whether it has been used previously. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of an IRF admission. You say all providers feel you are a good candidate for acute rehabilitation. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. 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 pre-approve Gemtesa.   
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve a Dexcom G7. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Dexcom G7. Our reviewer says that 
the documentation supports that the requested device is medically reasonable and necessary. Our physician 
reviewer found the enrollee has type 2 diabetes. The documentation shows that the enrollee is prescribed 
insulin and seems to take it if the enrollee's blood glucose is above a certain level. While the enrollee was last 
seen in December, the enrollee had an emergency for the six month follow-up, but has a scheduled 
appointment. The enrollee does meet criteria for the requested device. 
 
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 Dexcom G7 have been met. Therefore, we decided that the Plan has to pre-
approve a Dexcom G7.  
 
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.