Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for the water circulating heat pad with pump (E0217) 
billed for dates of service February 2, 2023, to February 24, 2023. 
 
You asked the Plan to pay for code E0217. You say that this item is medically necessary based on medical 
literature. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that water circulating heat pads with pumps 
(code E0217) are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for to pay 
for the water circulating heat pad with pump (E0217) billed for dates of service February 2, 2023, to February 
24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 28, 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 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31237 billed for date of service April 18, 
2023.  
 You asked the Plan to pay for procedure code 31237. You say that you have provided medical records to 
support 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 31237 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 31237 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 31237 billed for date of service April 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 rendered on December 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 64450-59-RT is considered inclusive to CPT 29848-RT. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that CPT 
code 64450-59-RT, an injection(s) of an anesthetic agent and/or steroid into other peripheral nerve or branch is 
documented in the notes submitted for review; however, this procedure is considered inclusive to CPT code 
29848-RT, a surgical wrist endoscopy, with release of transverse carpal ligament. The documents received do 
not support that the procedure or service was distinct or independent from other services performed; therefore, the requested CPT modifier is not supported. 
 
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 procedure code 64450 rendered on December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675) provided on 
February 20, 2023, through February 28, 2023. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
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 (E0675) provided on February 20, 2023, through February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease
Bundle (81479) provided to the enrollee on September 24, 2022.
You asked the Plan to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle. You say
that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says
that they have correctly denied the claim for payment as Z-Code Z00D5 is not covered for the MoIDX
program. Maximus overturned the Plan's denial. The Plan noted that per the DEX Diagnostic Exchange
Registry, the DEX Z-Code Z00D5 coverage status shows as "Not Covered" for Medicare billing. The Plan
included the registry page that confirms this.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case the reported
DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for
the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle (81479) provided to the enrollee on
September 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2022, to September 9, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2022, to September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac contractility modulation (CCM) device. 
 
You asked the Plan to pre-approve CCM device. You say that this is guideline-directed medical therapy. The 
Plan denied your request. The Plan says this procedure 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 CCM device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure remains the subject of multiple studies examining long-term efficacy. Until such 
studies are completed, it is premature to presume clinical outcomes and benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CCM device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac contractility modulation (CCM) device.
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 87799, 87500, 87652, 87640, 87900, 87798, and 87481. 
 
You asked the Plan to pay for the urine PCR panel testing. 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 testing 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 87799, 87500, 87652, 87640, 87900, 87798, 
and 87481.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the MI Tumor Seek Hybrid test (81479) provided on March 22, 2023. 
 
You asked the Plan to pay for the MI Tumor Seek Hybrid test. You say that this testing is covered under the 
MolDX program. The Plan denied your request. The Plan says that the doctor notes do not mention why this 
particular gene test was ordered, the number of genes tested, or how it will impact the enrollee's care. 
 
The Plan follows Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has either 
recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and, has not been previously 
tested with the same test using NGS for the same cancer genetic content, and has decided to seek further cancer 
treatment (e.g., therapeutic chemotherapy). 
 
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 MI Tumor Seek Hybrid test . Our 
reviewer says that this service is medically necessary. Our physician reviewer found that the enrollee meets all 
three criteria for coverage of NGS testing. Thus, the MI Tumor Seek Hybrid test is considered medically 
reasonable and 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 MI Tumor Seek Hybrid test have been met. Therefore, we decided that the 
Plan has to pay for the MI Tumor Seek Hybrid test (81479) provided on March 22, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  the telehealth services provided on February 22, 2023. 
 
You asked the Plan to pay for  the telehealth services. You say that the service should be covered. The Plan 
denied your request. The Plan says that Original Medicare is responsible for payment for clinical trials. 
 
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. The Plan hasnt provided any evidence that the enrollee was in a clinical trial or 
what the clinical trial is. Therefore, we decided that the Plan has to pay for  the telehealth services provided on 
February 22, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee needs this CGM. The Plan denied your 
request. The Plan says that medical records were not provided. 
 
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 a CGM. Our reviewer says that this 
CGM is medically necessary. Our physician reviewer found the enrollee is being insulin treated; therefore, a 
CGM is 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 a CGM have been met. Therefore, we decided that the Plan has to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM).  
 
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 the testing (81345) provided on November 4, 2022.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that they have correctly
denied the claim for payment as Z-Code ZBBIA is not covered for the MoIDX program. Maximus overturned
the Plan's denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code ZBBIA
coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that confirms
this.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case the reported
DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for
the testing (81345) provided on November 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 64479 and 64480 provided to the enrollee
on June 27, 2022.
You asked the Plan to pay for procedure codes 64479 and 64480. You say that you disagree with the denial.
The Plan denied your request. The Plan says that the claim for payment as the claim was billed with incorrect
place of service "11" when the member was an inpatient at the time when services were received.
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital
inpatients, the inpatient hospital POS code would be reported regardless of where the face-to-face service takes
place. POS code 21 is used to describe an inpatient hospital.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Specifically, this claim was not billed with the inpatient hospital
POS code. The records support that the enrollee was an inpatient in the hospital on the date of service these
services were provided. Therefore, we decided that the Plan does not have to pay for procedure codes 64479
and 64480 provided to the enrollee on June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is the appropriate 
level of care to make a full recovery. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 4, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim should not be denied for lack of 
authorization. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain independence before 
returning home. The Plan denied your request. The Plan says the medical records do not show a need for IRF 
services, and needs can be met in a different setting.  
 
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 enrollees rehabilitation needs can be safely provided in an alternate 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 16, 2022, 
through June 14, 2022.  
 You asked the Plan to pay for the home health services. You say that this was billed with the correct dates of 
service. The Plan denied your request. The Plan says the discharge status code and dates of service reported do 
not match.  
 
The Plan must follow Medicare rules. Medicare rules say that patient status code 06 is used when an enrollee is 
transferred to another home health agency or is discharged and readmitted within the same period. The rules 
also say that the dates in the statement covers period should either be 29 days between the From and Through 
dates, or the Through date should be reported as the date of discharge or transfer. 
 
We looked at the file and Medicare rules. This claim was billed with patient status code 06 which would 
indicate that the Through date on the claim would be listed as the date that the enrollee was discharged or 
transferred. This date would be less than 29 days from the From date. In this case, the claim reports 29 days in 
the statement covers period, which does not match with the status code of 06. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from May 16, 2022, through June 14, 
2022.