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

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided 
on January 6, 2023, and billed with codes 87500, 87641, 87796, G0452, 87471, 87481, 87551, 87651, and 
87653. 
 
You asked the Plan to pay for the wound PCR panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says per Local Coverage Article (LCA) A58726, this type of testing must 
be billed as a single unit of service with a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided on January 6, 2023, 
and billed with codes 87500, 87641, 87796, G0452, 87471, 87481, 87551, 87651, and 87653.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the gingival irrigation should not have been 
given before the deep cleaning. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the gingival irrigation is not covered by the Plan. 
 
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. 
 
  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 
gingival irrigation (D4921) provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the item is necessary. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 12, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete upper dentures (D5110).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the
enrollee's care needs and for them to receive therapy services. The Plan denied your request. The Plan says that
the enrollee does not meet the criteria for admission to an IRF. Maximus overturned the Plan's denial stating
IRF care is medically reasonable and necessary. The Plan requested a reopen and stated that Maximus did not
apply the correct criteria.

The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The records
clearly show that at the time of the appeal prior to admission the enrollee did not meet all the criteria required
by Medicare for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for iodine contrast supplies provided on  
June 27, 2023. 
 
You asked the Plan to waive the coinsurance for contrast supplies. You say that the charges were estimated to 
be $110. 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 20% 
coinsurance for in-network Medicare-covered medical supplies. The Plan contract also says that supplies for 
which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic 
procedures) are subject to this cost-sharing.  The allowed amount of the claim is $2,813.52, resulting in a coinsurance amount of $562.70 ($2,813.52 x 20% 
= $562.70), which is separate from your radiological diagnostic service copayment of $110. 
 
You have been asked to pay $562.70 for contrast supplies used during radiological diagnostic imaging. This 
item/service falls within the in-network Medicare-covered medical supplies 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 waive the coinsurance for iodine contrast supplies provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service July 20, 
2023.   
You asked the Plan to pay for procedure code 88291. You say that you would like the Plan to reconsider their 
denial of payment. 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 88291 is 1. The MAI value for this code is 3. You billed 4 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 88291 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88291 billed for date of service July 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on  
August 31, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the people performing 
your ambulance services were inept. 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 $275 
copayment per one way trip for in-network emergency and non-emergency ambulance services.  
 
 You have been asked to pay a $275 copayment for the ambulance services. 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. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on August 31, 2023.  
 
Your complaint about the ineptitude of the ambulance services is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 23, 
2023, through July 3, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that based on the medical records provided, the record does not show that at the time of the 
inpatient admission it was reasonable for the admitting physician to expect that the enrollee's necessary hospital 
care (including earlier Emergency Department (ED) and/or observation care) would span two midnights with 
supporting documentation of the enrollee's history and comorbidities, signs and symptoms, current medical 
needs, and risk of an adverse event. The provided records document that the enrollee's conditions stabilized and 
her symptoms improved in the emergency department and further evaluation and management could have been 
rendered at an observation level and/or with outpatient follow-up. Care at the observation level appears to have 
been appropriate with the option to transition the enrollee to an inpatient status if her condition warranted 
further hospital 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from June 23, 2023, through July 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 28m, 2023, and billed with codes 87481, 87482, 87500, 87652, 87798, 87799, and 87900. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on July 28m, 
2023, and billed with codes 87481, 87482, 87500, 87652, 87798, 87799, and 87900.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 28, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. 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 home visit provided 
on June 28, 2023.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that you are appealing the denial with supporting
documentation. The Plan denied your request. The Plan says that the enrollee does not meet all the
requirements based on Medicare guidelines.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that the documentation does not support that the complexity of the enrollee's nursing,
medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. The documentation does not support that the enrollee required treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program at least three hours a day for five days a week, or 15 hours over seven consecutive days. Our Medical
Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on August 15, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says all types of acupuncture including dry needling for 
any condition other than chronic low back pain are non-covered by Medicare. 
 
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.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture services are covered as long as the 
diagnosis is chronic low back pain. Therefore, we decided that the Plan does not have to pay for acupuncture 
services provided on August 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 4, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on July 11, 2023. 
 
You asked the Plan to pay for infrared therapy. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says the service performed is considered not 
reasonable and necessary by Medicare and is excluded from coverage. 
 The Plan must follow Medicare rules. Medicare rules say that the service provided is not reasonable and 
necessary. 
 
We looked at the file and Medicare rules. The rules say that infrared therapy is not reasonable and necessary. 
Based on this information, we decided that Medicare rules for coverage of infrared therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for infrared therapy provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings x-rays (V0274) provided on September 11, 2023.  
 
You asked the Plan to pay for the dental services. You say that you were never told in the office that you would 
have to pay for the service. 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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 7, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewings x-rays (V0274) provided on September 
11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says neuropsychological testing is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 pre-approve neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found utilizing the criteria from the Medicare LCD L34646 that 
this testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that 
impinge directly on or indirectly on the brain including detection of neurologic disease based on quantitative 
assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, 
delineation of neurocognitive effects of central nervous system disorders, neurocognitive monitoring of 
recovery or progression of central nervous system disorders or assessment of neurocognitive function for the 
formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders, 
this patient does not meet the criteria for psychological and neuropsychological testing as there does not appear 
to be a specific need for the testing which is asked for. Neuropsychological testing is not considered reasonable 
or medically necessary for the treatment of this patients condition utilizing the information provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backrest cushion and a bag hook (K0108). 
 
You asked the Plan to pre-approve a backrest cushion and a bag hook. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested cushion is not coded 
properly, and the bag hook set does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. The rules also say that for equipment to be covered, it must primarily serve a medical purpose.   
 
We looked at the file and Medicare rules. The file shows you are requesting a backrest cushion using not 
otherwise specified code, K0108. There are specific codes assigned to this type of item. In order to determine if 
Medicare criteria are met for the backrest cushion, the correct code must be requested. Additionally, the bag 
hook set 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 backrest cushion and a bag hook (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650) for 
tooth #27 and #29 provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was necessary for the teeth to be added to 
your existing partial. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for adding a tooth to an existing partial denture (D5650) for tooth #2 on June 14, 2023; 
therefore, your benefit for the requested items or services was exhausted on the date of service of June 14, 
2023. Therefore, we decided that the Plan does not have to pay for adding a tooth to an existing partial denture 
(D5650) for tooth #27 and #29 provided on June 14, 2023.