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

 
We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing 
provided on December 20, 2022. 
 
You asked the Plan to pay for urine PCR panel testing. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this test panel should be characterized by a single unit of service. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular syndromic panels for infectious 
disease testing must be billed with 1 unit of service of their proprietary procedure code, or if there is no 
proprietary procedure code then 1 unit of 87999 with the appropriate Z-Code for the test. 
 
We looked at the file and Medicare rules. This panel testing was not billed correctly. Based on this information, 
we decided that Medicare rules for coverage of urine PCR panel testing have not been met. Therefore, we 
decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing provided on 
December 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine. 
 
You asked the Plan to pre-approve the medication. You say that the request 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 prochlorperazine.  Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that the codes are payable. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 13, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the services ae not 
supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
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 96521 is refilling and maintenance 
of portable pump. We find that code 96521 is not supported in the medical record. The records do not 
document the refilling and maintenance of a portable pump. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 25, 2023, billed with 
codes 81272, 81345, 81314, and 81351. 
 
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 comprehensive cancer panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single panel as required. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on April 25, 2023, billed with codes 81272, 81345, 81314, and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code 99221 billed to the enrollee for 
January 3, 2022.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied 
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the 
Plans denial for insufficient claim information in the case file.

The Plan requested a reopen and submitted additional claim information. The Plan noted that the 
previous claim history shows the provider on the denied claim (570015742-00) for code 99221 for 
date of service (DOS) January 03, 2022, also submitted a claim. (32637446-00) for code 99223 for 
DOS January 03, 2022. Per the National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists between codes 99221 and 99223. This PTP edit has a modifier indicator of 0, which 
indicates there are no modifiers that are allowed with this PTP code pair.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that 
providers must report services correctly. In this case, this claim could not be paid as billed due 
to the PTP edit that exists between coded 99221 and 99223 both billed for the same date of service. 
Based on this information, we decided that Medicare rules for coverage of this claim have not been 
met. Therefore, we decided that the Plan
does not have to pay for procedure code 99221 billed to the enrollee for January 3, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the insertion of spinal neurostimulator pulse generator. We decided that 
the Plan does not have to waive the cost share amount for the surgical service provided in an outpatient hospital 
setting.  
 
You asked the Plan to pay for the insertion of spinal neurostimulator pulse generator or receiver (63685) 
provided in an outpatient hospital setting on June 23, 2023. You say that you were under the impression that 
this procedure was covered 100%. You say that the procedure was not 100% successful. You also say that you 
cannot afford to pay this. The Plan says that this is not a covered service. 
 
We decided that the Plan has to pay for the insertion of spinal neurostimulator pulse generator.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the insertion of the spinal neurostimulator pulse generator by a contract provider. The 
file does not show that the Plan provided notice that the insertion of the spinal neurostimulator pulse generator 
would not be covered. Under Medicare rules, this means the insertion of the spinal neurostimulator pulse 
generator is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the insertion of 
spinal neurostimulator pulse generator.  
 
We also decided that the Plan does not have to waive the cost share amount for surgical service provided 
in an outpatient hospital setting. 
 
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 hospital observation.  
 
You have been asked to pay a $200 copayment for the outpatient hospital services. The service falls within the 
outpatient hospital observation 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 pay for surgical service 
provided in an outpatient hospital setting. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, of 22 or more drug classes (G0483) 
provided on June 21, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that your facility is a reference laboratory. You 
only process all specimens that are sent to you by primary physicians that are participated in the insurance 
accepted. The Plan denied your request. The Plan says this service is not covered. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays and enzymatic methods (e.g., alcohol dehydrogenase)), (2) 
stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including 
metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the presumptive drug testing 
was performed at the same time. Definitive urine drug testing (UDT) is not reasonable and necessary when 
presumptive testing is performed at point of care. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for definitive drug testing, of 22 or more drug classes (G0483) provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that the requested CGM is 
medically necessary. The Plan denied your request. The Plan says that the denial of authorization for the 
requested CGM is correct, because the Freestyle Libre 3 is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor (CGM). 
Our reviewer says that the CGM coverage criteria was met. Our physician reviewer found that the record 
indicates that the enrollee has diabetes and has sufficient training to use a continuous glucose monitor. The 
record provided documents that the enrollee is treated with insulin and had a face-to-face encounter with the 
treating practitioner. The elements of the coverage criteria are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of the continuous glucose monitor (CGM) have been met. Therefore, 
we decided that the Plan has to pre-approve a Freestyle Libre 3.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee was independent at home without 
supervision and continues to have left side weakness needing assistance. The Plan denied your request. The 
Plan says the enrollee may benefit from continuing physical and occupational therapy, but the records do not 
support the need for daily therapy in a SNF setting. The Plan says services may be provided at a lower level of 
care. 
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87641 and 87500. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 87640-59 and 
87491-59.  
 
You asked the Plan to pay for the lab testing billed for date of service July 25, 2023. You say that the coding is 
approved by Medicare. The Plan says that the billed codes are not supported. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87641 and 87500.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 87641 and 87500 billed for 
date of service July 25, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
87640-59 and 87491-59. 
 
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 looked at the file and Medicare rules. The NGS panel was not billed with a single code as required. The 
records do not show that the service billed with code 87491 was ordered or provided. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 
87640-59 and 87491-59 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 87640-59 and 87491-59 billed for date of service July 25, 2023. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided on 
October 23, 2023. 
 
You asked the Plan to pay for the LTACH services. You say that the enrollee is still ventilator reliant overnight 
and is very slowly progressing towards tolerating high humidity oxygen in increasing intervals. You say that 
the enrollee also requires continued physical therapy and occupational therapy for severe critical illness 
myopathy. The Plan denied your request. The Plan says that the enrollee can receive this care in the current 
acute care setting. 
 
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 pay for 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 does not require services at the LTACH that are not available at the acute care 
hospital. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pay for long term acute care hospital (LTACH) services provided on October 23, 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 needs this care to return to 
previous living situation. The Plan denied your request. The Plan says the enrollee does not require services at 
the LTACH that are not already available at the current facility.  
 
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 is still undergoing acute hospitalization and requires additional 
treatments and documentation of neurological improvement expectations. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service June 6, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says there is a more 
appropriate code to support the services. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, there is a more applicable 
code available that accurately described the services provided. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code G0482 billed for date of service June 6, 2023.