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

 
We decided that the Plan does not have to pay for SNF care provided from June 3, 2023, to June 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 was only a custodial resident from June 3, 2023, to June 19, 
2023. 
 
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 require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require 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 June 3, 2023, to June 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for  inpatient hospitalization services provided from December 12, 2022, to December 15, 2022.

You asked the Plan to pay for the services. You say that  you are requesting medical review and an immediate adjudication of this claim based on medical necessity of the primary diagnosis and the treatments. The Plan denied your request. The Plan says after stabilization of the enrollee's clinical condition in the emergency department, the health plan should have been given the opportunity, in a timely manner, to transfer the enrollee to an in-network facility, and/or involve contracted providers in the care, and/or provide utilization management oversight to the care the enrollee. The Plan also says the records indicate that the enrollee was stabilized and not in any immediate danger at the time of inpatient admission.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 services. Our physician reviewer found there was normal white blood count (WBC) count, no fever. The enrollee refused prophylactic antibiotics for the enrollee's chronic wounds. On December 12, 2022, the notes describe the enrollee as tolerating low dose oxygen support and hemodynamically stable. There was no documentation describing the enrollee as too unstable for transfer for any date. According to the provided documentation, the enrollee was stable for transfer 13:36 on December 12, 2022.

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 pay for  inpatient hospitalization services provided from December 12, 2022, to December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics (D6245), retainer crowns (D6740), and core build-
ups (D2950) provided on July 17, 2023, to August 1, 2023. 
 
You asked the Plan to pay for D6245, D6740 and D2950. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the denied dental services are not covered benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pontics 
(D6245), retainer crowns (D6740), and core build-ups (D2950) provided on July 17, 2023, to August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the closed treatment of a distal radial fracture described by 
code 25600 performed on May 5, 2023.  
 
You asked the Plan to pay for 25600. You say that 25600 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 25600 is denied because it is not supported in the 
documentation. 
 
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 code 25600 is closed treatment of distal radial fracture (for 
example, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, 
when performed; without manipulation. 
 
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 25600. Our reviewer says that 25600 is not supported in the 
documentation. Our reviewer found the medical record describes an emergency department visit for a fracture, 
however it does not include documentation of fracture treatment. This procedure or a procedure report was not 
found in medical record, and therefore 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 25600 have not been met. Therefore, we decided that the Plan does not have to 
pay for the closed treatment of a distal radial fracture described by code 25600 performed on May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 23, 2023, billed with 
multiple codes including 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
June 23, 2023, billed with multiple codes including 81433.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83789 and G0480 billed for date of service 
July 1, 2023. 
 
You asked the Plan to pay for procedure codes 83789 and G0480. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 83789 and G0480 is bundled into 
payment for code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, we have confirmed that codes 83789 and G0480 are column II codes to column I code 80307. 
While code 83789 was billed with modifier -59, the medical records provided do not show that the service 
billed with the -59 modifier is a distinct procedural service. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 83789 and G0480 billed for date 
of service July 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for out-of-network podiatry visits provided on July 19, 2023, to August 02, 2023.

You asked the Plan to waive the copayment for out-of-network podiatry visits. You say that you chose this provider from the plan website, there should not be a copay. 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 $30 copayment for podiatry services.

You have been asked to pay a $30 copayment for out-of-network podiatry visits. This item/service falls within the podiatry 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. The total you owe is $90 ($30 copayment per visit x 3 visits = $90). Therefore, we decided that the Plan does not have to waive the copayment for out-of-network podiatry visits provided on July 19, 2023, to August 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210), and fluoride varnish (D1206) 
provided on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been processed correctly. 
 
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, certain limitations apply. The record 
shows your benefit for D0210 was exhausted on date of service May 5, 2023. D1206 is not a covered dental 
benefit. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210), and fluoride 
varnish (D1206) provided on May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81003 and 85025 provided on June 13, 
2023.  

You asked the Plan to pay for procedure codes 81003 and 85025. 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 81003 and 85025 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 in the custom 
panel. Based on this information, we decided that Medicare rules for coverage of procedure codes 81003 and 
85025 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81003 
and 85025 provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded as 64447 and the radiology 
services coded as 76942 billed on date of service September 26, 2022. 
 
You asked the Plan to pay for 64447 and 76942. You say that 64447 and 76942 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 64447 and 
76942 are denied because they are not supported in the documentation. 
 
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 code 64447 is injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve, including imaging guidance, when performed. 
 
The CPT Code Manual definition of code 76942 is ultrasonic guidance for needle placement (for example, 
biopsy, aspiration, injection, localization device), imaging supervision and interpretation. 
 
We find that CPT code 64447 and 76942 are not supported in the medical record. We confirmed the provided 
records in this case do not contain a post-operative pain management note. While the records include an 
anesthesia and operative report for a total knee arthroplasty and there are orders for post-anesthesia care, there 
is no documentation of the injection of an anesthetic agent and/or steroid; femoral nerve, including imaging 
guidance, when performed. Therefore, code 64447 cannot be verified. Regarding code 76942, the records do 
not contain documentation of any ultrasonic guidance for needle placement, with imaging supervision and 
interpretation, as required for reporting 76942, therefore, this code is also not supported. Based on this 
information, we decided that Medicare rules for coverage of 64447 and 76942 have not been met. Therefore, 
we decided that the Plan does not have to pay for the injection services coded as 64447 and the radiology 
services coded as 76942 billed on date of service September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade 
to expandable controller (E2313), and electronic connection between wheelchair controller and two or more 
power seating system motors (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has adequate strength to 
manage standard power drives. 
 
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 electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for 
upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and two or 
more power seating system motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedures, by 
report (D5899 x 4) provided on July 13, 2023 and August 3, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
supplemental dental policy.  
  
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
removable prosthodontic procedures, by report (D5899 x 4) provided on July 13, 2023 and August 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BMP allograft (20930). 
 
You asked the Plan to pre-approve the BMP allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 BMP allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 BMP allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the BMP allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87801 provided on July 27, 
2023. 
 
You asked the Plan to pay for procedure codes 87150 and 87801. 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 covered as 
billed. 
 
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 procedure codes 87150 and 87801 provided on July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2023, billed with 
codes 81226, 81227, 81241, 81306, 81328, 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. 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. 
 
The file shows that a combined cardio and pharmacogenetics test panel was provided. We looked at the file and 
Medicare rules. This NGS panel was not billed with a single 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 31, 2023, billed with codes 81226, 
81227, 81241, 81306, 81328, 81335.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liver function study. 
 
You asked the Plan to pre-approve liver function study. You say that this scan will allow you to better identify 
the underlying cause of the enrollee's symptoms. The Plan denied your request. The Plan says having an exam 
done without provocation is redundant and unnecessary. 
 
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 liver function study. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was a request for 2 nuclear medicine hepatobiliary iminodiacetic acid (HIDA) scans. The first exam, which was approved, was a HIDA scan with provocation. This second scan is a HIDA 
scan without provocation. Since the former approved scan includes imaging without provocation, this scan is 
unnecessary and duplicative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of liver function study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a liver function study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an outdoor scooter.

You asked the Plan to provide coverage for an outdoor scooter. You say that an outdoor scooter is needed for
appointments and outdoor mobility. The Plan denied your request. The Plan says this equipment is not covered
for outdoor use. Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus
did not apply the correct criteria.

The Plan is correct in this case. The Plan follows Medicare rules. Medicare only covers a power scooter for use
in the home. Medicare goes not cover a power scooter to unable out of the home mobility. This equipment was
specifically requested for outdoor use. Therefore, we decided that the Plan does not have to provide coverage
for an outdoor scooter.