Persius/hicric huggingface dataset:
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 April 27, 2023, and billed with codes 87481, 87556, 87640, 87798, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. 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 a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR 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 April 27, 2023, and billed with codes 87481, 87556, 87640, 87798, and 87653.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 24, 2023. 
 
You asked the Plan to pay for the medical services. You say that the patient was not on hospice on the date of 
service in question. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 23, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for dialysis treatment provided from  
November 4, 2022, to November 16, 2022 in Argentina. 
 
You asked the Plan to reimburse you for the dialysis treatment. The Plan denied your request. The Plan says 
your Plan covers services for emergency medical conditions, or urgently needed services when you are 
temporarily absent from the plan service area and outside of the United States. The dialysis services you 
received in Argentina were not services received as a result of an unforeseen illness, injury, or condition. You 
need dialysis chronically and thus this request is not covered as an urgent or emergent service. 
 
The Plan contract covers emergency care worldwide. 
 
We looked at the file and the Plans rules. The file shows that the dialysis treatment received was not due to an 
emergency. Therefore, we decided that the Plan does not have to reimburse you for dialysis treatment provided 
from November 4, 2022, to November 16, 2022 in Argentina.
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 IRF admission is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says the enrollee does not meet the criteria for the IRF 
admission. 
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee can receive further services at a lower 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99204 provided to the enrollee on August 5,
2022.
You asked the Plan to pay for procedure code 99204. You say that these services were medically necessary.
The Plan denied your request. The Plan says that medical records submitted don't support moderate level of
medical decision making or total time required of the code billed and that multiple attempts were made to
contact the provider for additional information. Maximus overturned the Plan's denial. The Plan requested a
reopening and confirmed procedure code 20550 was approved and paid. The Plan also states that records were
not submitted to support procedure code 99204. The Plan is correct in this case. In this case, the CPT Code
Manual definition of code 99204 is new patient office or other outpatient visit, 45-59 minutes. The records
provided do not confirm the visit was for 45-49 minutes and without this documentation the services cannot be
confirmed. Therefore, we decided that the Plan does not have to pay for procedure code 99204 provided to the
enrollee on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that you did not have correct insurance payor information 
at time of service. The Plan denied your request. The Plan says the provider should have submitted claim 
sooner. 
 
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 an office visit was not filed until May 31, 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 an office visit provided on May 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 22, 2023, 
to April 05, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that it is medically necessary. 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 subsequent nursing 
facility care provided on March 22, 2023, to April 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve spinal surgery. You say that you are appealing the denial because the 
enrollee would like to continue treatment with the OON provider. The Plan denied your request. The Plan says 
that there are several in-network providers who can provide this service to the enrollee. 
 
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 
spinal surgery 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 a replacement knee and a REVO socket for a leg 
prosthesis. 
 
You asked the Plan to pre-approve a replacement knee and a REVO socket. You say that the requested items 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are 
not medically necessary. The REVO socket is experimental/investigational. 
 
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 a replacement knee and a REVO 
socket. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee's current K3 microprocessor knee does 
not appear to have irreversible damage and the enrollee does not appear to have a physiologic change that 
requires a new knee. The documentation is conflicting on the age of the current knee, but it appears that the 
current knee appears to be still under warranty, and per the March 30, 2023, prosthetic consultation, the knee 
was 5 months old at that time. Additionally, the enrollee was approved for a standard socket. The REVO socket 
is not Food and Drug Administration (FDA)-approved; therefore, this item does not meet Medicare criteria as 
safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a replacement knee and a REVO socket have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement knee and a REVO socket for a leg prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 30, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for 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 office visit provided on 
April 30, 2023.
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 enrollee's condition requires an 
LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and is currently unstable for transfer to an LTACH. 
 
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 record indicates that the enrollee remains critically ill and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that are not currently being received but that would 
be available at the LTACH facility. The requested service cannot be recommended as the elements of the 
coverage rules are not satisfied. . 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 38724 provided to the enrollee on October
12, 2022.
You asked the Plan to pay for procedure code 38724. The Plan denied your request. The Plan says the service
at issue was not billed with the required modifier to allow separate payment within the global surgery period.
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical
procedures, which should be billed with modifier -79.
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 40530
provided on September 28, 2022. We find that the service at issue may be unrelated to the surgical procedure;
however, the required modifier to indicate this was not used. As such, the billing rules for these services have
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 38724 provided to
the enrollee on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 93922 billed for date of service January 17,
2022.
You asked the Plan to pay for procedure code 93922. 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 claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 93922 is 2. The MAI value for this code is 2. You billed 3 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of
procedure code 93922 have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 93922 billed for date of service January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2023. 
 
You asked the Plan to pay for the genetic testing billed. You say that the claim is billed correctly and should be 
paid. 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 
March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on March 16, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the definitive drug testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is not covered when provided OON. 
 
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 definitive drug testing provided on March 16, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure from chronic obstructive pulmonary disease (COPD). The provided primary source documentation does 
not contain sufficient detailed information in the medical record to justify the treatment selected. Failure of bi-
level positive airway pressure (BiPAP) therapy with average volume-assured pressure support (AVAPS) is not 
documented. The criteria for coverage are not met and the ventilator is not reasonable or medically necessary. 
 
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 pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15853 billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for procedure code 15853. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this code is not paid separately when it is performed in 
the place of service billed on this claim. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 15853 is not supported in the medical record. Specifically, CPT code 15853 has a 
PC/TC indicator of 5. This claim was billed with place of service (POS) code 23, which is a hospital 
emergency room. This code cannot be paid when it is billed in a hospital setting. Based on this information, we 
decided that Medicare rules for coverage of procedure code 15853 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 15853 billed for date of service March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided to the enrollee on January
17, 2022.
You asked the Plan to pay for the wound care supplies. You say that the supplies are separately payable. The
Plan denied your request. The Plan says that these items are included in the payment for SNF services.
Maximus overturned the Plan's denial. The Plan requested a reopening and stated that the enrollee was
receiving SNF services when these items were provided. The Plan is correct in this case. The Plan has provided
claim documentation to show the enrollee was staying at a SNF from January 8, 2022, through January 22,
2022. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the
home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wound care
supplies were used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the
wound care supplies provided to the enrollee on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 82728, 83036, 83540, and 83550 for date of service 
February 28, 2023. 
 
You asked the Plan to pay for codes 82728, 83036, 83540, and 83550. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 82728, 83036, 83540, and 83550 are not supported in the medical record. Specifically, 
the documentation did not include clinical records to support the necessity of the services rendered. Based on 
this information, we decided that Medicare rules for coverage of codes 82728, 83036, 83540, and 83550 have 
not been met. Therefore, we decided that the Plan does not have to pay for codes 82728, 83036, 83540, and 
83550 for date of service February 28, 2023.