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

We decided that the Plan does not have to pay for lab services provided to the enrollee and billed under code
81335 billed for date of service December 13, 2022.

You asked the Plan to pay for this claim. You say that the Plan should pay these services. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted the jurisdiction for a reference lab claim comes from the billing provider in
box 11 which shown on the claim is Louisiana. The Medicare Claims Processing Manual Chapter 16 Section
50.5.1 states, "regardless of whether the laboratory that bills Medicare is the referring or reference laboratory,
the laboratory that does the billing may bill only the A/B MAC (B) that services the jurisdiction in which the
billing laboratory is physically located. The location of the draw station, when a separate draw station is
employed, never determines claims filing jurisdiction. The Medicare Local Coverage Article (LCA) Billing and
Coding: pharmacogenomics Testing (A58801) shows the list of medical necessity denials for code 81335, of
which none were billed on the claim.

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, the diagnosis reported do not support the services billed. Medicare rules
for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab
services provided to the enrollee and billed under code 81335 billed for date of service December 13, 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 require rehabilitation services before returning 
home. The Plan denied your request. The Plan says you do not meet the 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has failed numerous 
lumbar epidural steroid injections, facet injections and medial branch blocks. You say that the enrollee's pain is 
worst with prolonged sitting and standing rather than walking. The Plan denied your request. The Plan says that 
the Intracept procedure is not medically necessary. 
 
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 the Intracept procedure. Our reviewer 
says that that the Intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease or 
stenosis, and the cause of pain is not clear. Therefore, the coverage criteria have not been met.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (intraosseous ablation of the basivertebral nerve).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
gradient pressure pneumatic appliance (E0671), to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and segmental gradient pressure pneumatic 
appliance . You say that the items are medically necessary. The Plan denied your request. The Plan says there 
are in-network providers available that the enrollee can obtain these items through. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0652) and segmental gradient pressure pneumatic appliance (E0671), to be provided 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alcohol wipes to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve alcohol wipes. You say that the supplies should be covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
alcohol wipes to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertiflex. 
 
You asked the Plan to pre-approve vertiflex. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
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 vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found vertiflex is experimental. more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve vertiflex.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex care needs. The Plan denied your request. The Plan says the enrollee can stay in the 
hospital until they are safe for transfer or discharge.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the hospital for difficulty breathing. The enrollee is not 
intubated but does require high flow nasal cannula. The enrollee is not safe for transfer at this time. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the heart for calcium 
scoring. 
 
You asked the Plan to pre-approve the CT scan. You say that you have a family history of heart issues, and the 
test was recommended by your doctor. The Plan denied your request. The Plan says that the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the documented 18% 10-year risk of heart 
disease qualifies the patient for the requested CT calcium scoring. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the heart for calcium scoring.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for panoramic imaging D0330), and a comprehensive oral 
evaluation (D0150) provided on August 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you need this dental work. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing 
amount when your services are received from an out-of-network provider.  
 
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.  

You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment for D0150. D0330 was exhausted on August 23, 2023. 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 pay 
more for panoramic imaging D0330), and a comprehensive oral evaluation (D0150) provided on August 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel test billed for date of service March 30, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that the billed codes are the most accurate to describe 
the services performed. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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.  
 
The file shows that the panel testing was billed using codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 
87640, 87651, and 87798. 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 respiratory panel test billed for date of service 
March 30, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary to save your 
foot. The Plan denied your request. The Plan says you do not meet the 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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: 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 IRF care is preferred to assist with healing. The Plan 
denied your request. The Plan says IRF care is not reasonable and necessary.  
 
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 the complexity of your nursing, medical, and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical records support a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder (K0108). 
 
You asked the Plan to pre-approve a cup holder. You say that this is a request to repair equipment that was 
already approved. You also say that therefore, medical necessity has already been established. The Plan denied 
your request. The Plan says this item does not serve a medical need and cannot be covered.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cup holder (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on 
October 9, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. A PCD coded as E0675 to treat peripheral arterial disease is not eligible 
for reimbursement. There is insufficient evidence to demonstrate that reimbursement is justified. Claims for 
E0675 will be denied as not reasonable and necessary.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) provided on October 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502 and 87634 provided on March 29, 
2023. 
 
You asked the Plan to pay for procedure codes 87502 and 87634. 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 codes 87502 and 87634 are 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. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 87502 and 87634 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87502 and 87634 provided 
on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for photochromatic tint (V2744) provided on July 25, 
2023. 
 
You asked the Plan to reimburse for photochromatic tint. You say that the glasses you received are from after 
cataract surgery. The Plan denied your request. The Plan says photochromatic tint (V2744) has been redenied 
as this is not a covered service under the members basic/medical vision benefits. 
 
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 these services after cataract surgery when the lenses are standard lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one pair of eyeglasses or 
contact lenses after each cataract surgery that includes insertion of an intraocular lens. The Plan rules also say 
that covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any 
upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses, or anti-
reflective coating). Based on this information, we decided that the Plan's rules for coverage of photochromatic 
tint have not been met. Therefore, we decided that the Plan does not have to reimburse for photochromatic tint 
(V2744) provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 3, 2023, billed with 
procedure codes 81240-59, 81241-59, and 81328-59. 
 
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 documentation does not support the billed codes. 
 
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 codes 81240-59, 81241-59, and 81328-59 is F2 (prothrombin, 
coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant, F5 (coagulation 
factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant, and SLCO1B1 (solute carrier 
organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) 
(eg, *5).  
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the laboratory report documents 
"Buccal Swab". The procedure is performed with whole blood. Therefore, procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 3, 2023, billed with procedure codes 
81240-59, 81241-59, and 81328-59.