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

 
We decided that the Plan does not have to pay for the lab panel provided on June 26, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one 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 lab panel provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 81335 provided on May 25, 
2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed with code 81335 provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and connection. You say that these items 
are necessary. The Plan denied your request. The Plan says the enrollee can control the power options with 
their own switches. 
 
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 an expandable controller, harness, and 
connection. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee has use of the upper extremities and can operate and 
control the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness 
(E2313), and connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 2, 2022, billed 
with codes 81216, 81298, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 2, 2022, billed with codes 81216, 81298, and 81317.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a raised toilet seat (E0244) purchased June 7, 
2023. 
 
You asked the Plan to reimburse you for a raised toilet seat. You say that you received $17.50 for the raised 
toilet seat. You would like to receive full reimbursement. The Plan denied your request. The Plan says the cost 
sharing will be applied according to the Plan contract. 
 
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 20% of 
the approved amount for Medicare covered services.  
 
You have asked for full reimbursement for the purchase of a raised toilet seat. The maximum Medicare allowed 
amount for this item is $17.50. The Plan has reimbursed this amount to you. This item/service falls within the Durable medical equipment (DME) and related 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 
reimburse you for a raised toilet seat (E0244) purchased June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab testing on January 16, 2023.  
 
You asked the Plan to waive the deductible for the lab testing. You say that you were never informed about the 
sample being sent to two labs and that you were never provided with a bill or explanation of benefits. 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. Your 
contract with the Plan says that there is a $190 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $190 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the lab testing was received on January 16, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for the lab testing on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service April 12, 
2023. 
 
You asked the Plan to pay for procedure code 99072. You say that you we have already received denial from 
the Independent Physician Association (IPA) stating that it is responsibility of the Plan because this is the 
COVID claim. The Plan denied your request. The Plan says procedure code 99072 is considered bundled and 
not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for therapeutic interventional radiological 
procedures provided on July 26, 2023. 
 
You asked the Plan to pay for anesthesia for therapeutic interventional radiological procedures. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for anesthesia for therapeutic interventional radiological procedures was not 
filed until August 11, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for anesthesia for therapeutic 
interventional radiological procedures provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 the laboratory services 
provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pigmented Lesion Assay (0089U) provided on November 
16, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you request for an overturn of the denial and 
reprocessing of the claim. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 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 Pigmented Lesion Assay (0089U) provided on 
November 16, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided March 
23, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the surgery was approved, and the 
physician specifically requested that this medically necessary device be dispensed to the enrollee to aid in 
healing at the enrollee's home. The Plan denied your request. The Plan says pneumatic compression device is 
not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tendon injection provided from 
02/14/2022, to 04/14/2023. 
 
You asked the Plan to waive the copayment for a tendon injection . You say that you should not owe this bill. 
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 $200 
copayment for outpatient services not provided in an ambulatory surgical center.  
 
You have been asked to pay a $200 copayment for a tendon injection. This item/service falls within the 
outpatient services not provided in an ambulatory surgical center 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 tendon injection provided from 02/14/2022, to 04/14/2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
April 21, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 urine polymerase chain reaction (PCR) 
panel rendered on April 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire. 
 
You asked the Plan to pre-approve Tezspire. You say that the medication is medically necessary. 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 Tezspire.  Benefits for Tezspire 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve transcranial magnetic stimulation (TMS). You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the order or treatment is 
written by a psychiatrist (MD or DO) who has examined the patient and reviewed the record. 
 
The Plan follows Medicare rules. Medicare rules say that the order for treatment (or retreatment) is written by a 
psychiatrist (MD or DO) who has examined the enrollee and reviewed the record. 
 
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 transcranial magnetic stimulation 
(TMS). Our reviewer says that the service is not medically necessary. Our physician reviewer found based on 
the information provided, this enrollee does not meet the clinical criteria for the use of transcranial magnetic 
stimulation (TMS) therapy the enrollee has not undergone psychotherapy and is there is no baseline testing 
including a patient health questionnaire (PHQ) 9 or generalized anxiety disorder (GAD) 7. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcranial magnetic stimulation (TMS) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the PT services. You say that you would like to receive services at this 
office as they have a good reputation. The Plan denied your request. The Plan says the requested facility does 
not participate with Medicare. The Plan also says that providers must participate with Medicare in order to 
receive payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the mount/night guard provided on August 9, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to reimburse for the mount/night guard. You say that you feel it covered. The Plan denied 
your request. The Plan says the enrollee must use network providers to get their medical care and services. If 
enrollee goes elsewhere without proper authorization the enrollee will have to pay in full. The only exceptions 
are emergencies, urgently needed services when the network is not available (that is, in situations when it is 
unreasonable or not possible to obtain services in-network), out-of-area dialysis services, and cases in which 
the Plan authorizes use of out-of-network providers. 
 
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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the mount/night guard provided on August 
9, 2023, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that the requested drug is medically necessary to treat the 
enrollee's diagnosis. The Plan denied your request. The Plan says the enrollee does not meet the step-therapy 
requirements for approval. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that the 
requested drug does not meet the requirements necessary for approval. Our physician reviewer found the Plan 
requires a trial of Monovisc, Orthovisc, or Synvisc/Synvisc-One before they will approve the requested drug. 
The requested medication is a new start. The provided records do not indicate that you have tried and failed the 
plan's preferred step one alternative. The record does not indicate that you have a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are 
not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan noted that the medical records show at the time of the appeal the enrollee was
functioning close to baseline. The enrollee's prior level of functioning was modified independent. The
enrollee's level of function at the time of the appeal required contact guard assistance for transfers and
ambulation with distance and use of an assistive device.

The physical therapy records note a recommendation for skilled nursing facility services. The medical records
do not show the enrollee required daily skilled therapy and physician evaluation or at an IRF level of care.

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
medical records do not show an expectation for the enrollee to have the ability to participate in or benefit from
a rehabilitation program to include 3 hours a day for 5 days a week of intensive therapy. Based on the medical
records provided, the enrollee did not meet the required criteria for IRF admission at the time of the appeal.
Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility
(IRF) admission and services for the enrollee.