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

 
We decided that the Plan does not have to pay for the genetic testing provided on May 25, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 
81408, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that please find the attached documents, 
review and reconsider the claim for payment. 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 
May 25, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 
81404, 81405, 81406, 81407, 81408, 81479.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy for the enrollee.

You asked the Plan to pre-approve sclerotherapy. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for sclerotherapy. Our
Medical Director states that the documentation does not support that the enrollee in this case had any of the
following signs and symptoms of significantly diseased vessels of the lower extremities are documented in the
medical record: stasis ulcer of the lower leg, significant pain and significant edema that interferes with
activities of daily living, bleeding associated with the diseased vessels of the lower extremities, recurrent
episodes of superficial phlebitis, stasis dermatitis, or refractory dependent edema. Our Medical Director found
that the enrollee's condition does not meet criteria for coverage of sclerotherapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve sclerotherapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided on October 24, 2022, billed with procedure code 01638.
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of service.
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. This claim was inappropriately billed with POS 21 as documentation shows that the enrollee was registered outpatient on this date of service. Therefore, we decided that the Plan does not have to pay for practitioner services provided on October 24, 2022, billed with procedure code 01638.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on June 20, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on June 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from May 7, 2023, to May 19, 2023. 
 
You asked the Plan to pay for SNF care. You say that the SNF services were medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition no longer required SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from May 7, 2023, to May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required  
(D2950 x 2) and porcelain/ceramic crowns (D2740 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says a core buildup is not a covered benefit under the 
supplemental dental policy. Additionally, you have exhausted the allowable benefit for the dental crowns 
requested in this case.   
 
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 core buildups in this case 
are not among those covered under this benefit. Additionally, you have exhausted the allowable benefit for the 
dental crowns requested in this case. Specifically, the Plan's contract states that one dental crown is covered 
per year. You previously received a dental crown on February 24, 2023, less than one year prior, which was 
paid for by the Plan. Therefore, you have exhausted the allowable benefit for this item. Therefore, we decided 
that the Plan does not have to pre-approve core buildups, including any pins when required (D2950 x 2) and 
porcelain/ceramic crowns (D2740 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous left atrial appendage closure (LAAC) 
(33340) and transesophageal echocardiogram (TEE) (93312). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary because the records do not show 
documentation of shared decision making by an independent non interventional physician. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the inability to tolerate anticoagulation is not confirmed and rationale for LAAC is unclear. Moreover, 
while there is reference to consideration of the LAAC, there is no documentation of performance of an 
evidence-based shared decision-making interaction on anticoagulation. As such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous left atrial appendage closure (LAAC) (33340) and transesophageal 
echocardiogram (TEE) (93312).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
08, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for physician/practitioner services. 
 
You have been asked to pay a $15 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner 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 a 
specialist office visit provided on June 08, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on July 20, 2023. 
 
You asked the Plan to pay for psychotherapy services (90837). You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy services 
(90837) provided on July 20, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy services (90853) provided on July 17, 
2023. 
 
You asked the Plan to pay for group psychotherapy services (90853). You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for group psychotherapy 
services (90853) provided on July 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided from September 29, 2022, to
October 15, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional clarification. The Plan noted that Federal Information Processing System (FIPS) code 38060 is
invalid. The provider reported FIPS code 38060 as both the core based statistical area (CBSA) code and the
FIPS code. This is a valid CBSA code and is not a valid FIPS code. The Plan notes per the United States (US)
Census, the FIPS code consists of five digits, the first two being the state code and remaining three being the
county code. This provider is in Maricopa County Arizona. Per the US Census website, the proper FIPS code
for Maricopa County in Arizona is 04013. Per the US Census website, the FIPS code 38060 does not exist.
Therefore, this claim could not be paid as billed.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim was submitted with an invalid FIPS code. Medicare rules for
payment of these services have not been met. Therefore, we decided that the Plan does not have to pay for
home health services provided from September 29, 2022, to October 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on November 18, 2021 
to November 21, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately. The Plan denied your request. The Plan says some 
diagnoses reported on this claim are not supported in the clinical documentation provided. Therefore, the DRG 
reported has been changed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
 In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our physician reviewer found there was no report of mental status changes or oliguria. Based on the Sepsis 3 criteria, the patient only had a Sequential Organ Failure Assessment (SOFA) score of 1 for at times low blood pressure, however, there were no other significant findings indicating organ failure due to a dysregulated response to systemic infection to justify the code, A41.9 (sepsis).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 18, 2021 to November 21, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
June 12, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you had no choice 
but to use the ambulance services. 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 for ambulance services. 
 
You have been asked to pay a $275 copayment for the ambulance transportation. 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 transportation provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service May 28, 
2023.  
 
You asked the Plan to pay for procedure code 93010. You say that the claim is billed correctly and should be 
paid. 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 93010 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 93010 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93010 billed for date of service May 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 31, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be charged for an 
office visit. 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 $15 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for an office visit. This item/service falls within the in-network 
physician/practitioner services, including doctors office visits 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 an office visit provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 2, 2023, to 
March 4, 2023.  

You asked the Plan to pay for home health services. You say that the services at issue were paid in cash. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 home health services have been met. 
Specifically, you have not provided proof of payment for the services at issue. Therefore, we decided that the 
Plan does not have to pay for home health services provided from March 2, 2023, to March 4, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy services (90853) provided on July 11, 
2023. 
 
You asked the Plan to pay for group psychotherapy services (90853). You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for group psychotherapy 
services (90853) provided on July 11, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on April 26, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy. You say that the physical therapy service was medically 
necessary for out-of-network. The Plan denied your request. The Plan says the services were available with in-
network providers and not authorized for out-of-network. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on April 
26, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on June 19, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on June 19, 2023.