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

We decided that the Plan does not have to provide coverage for a vacuum assisted socket system (VASS)
(L5781) for the enrollee.

You asked the Plan to provide coverage for a vacuum assisted socket system (VASS) (L5781). The Plan denied
your request. The Plan says a vacuum assisted socket system (VASS) (L5781) is not covered in this case.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. We looked at the file and Medicare rules. The current guidance states the use
of vacuum pumps for residual limb volume management and moisture evacuation systems among amputees is
unproven and not medically necessary due to insufficient evidence of safety and efficacy. Based on this
information, we decided that there is insufficient information in the record to determine if Medicare rules for
coverage of a vacuum assisted socket system have been met. Therefore, we decided that the Plan does not have
to provide coverage for a vacuum assisted socket system (VASS) (L5781) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an Ottobock C-leg microprocessor knee.

You asked the Plan to provide coverage for an Ottobock C-leg microprocessor knee. The Plan denied your
request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan noted the medical records do not show why a mechanical knee cannot be used for the enrollee's
prosthesis, especially given the weight a microprocessor knee and the enrollee's co-morbidities. The Plan notes
a microprocessor knee weighs more than a mechanical knee. A microprocessor knee is more prone to
damage and corrosion, especially when exposed to water. A microprocessor knee requires more maintenance,
such as maintenance of charge for the battery, and avoidance of water. The records provide do not support the
need for this upgraded equipment.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we
decided that there is insufficient information in the record to determine if Medicare rules for coverage of
Ottobock C-leg microprocessor knee have been met. Therefore, we decided that the Plan does not have to
provide coverage for an Ottobock C-leg microprocessor knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering (L5962), flex foot 
system (L5981), and heavy-duty feature (L5995) for a lower limb prosthesis. 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that the enrollee wants comfort, 
convenience, and safety in a prosthetic leg. The Plan denied your request. The Plan says the protective outer 
surface covering is not necessary because a standard prosthetic covering would be sufficient and codes 
L5980/L5995 are miscoded as the requested foot is categorized as L5981. 
 
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 lower limb prosthetic components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records do not document that the patient will be exposed to such an 
unusually harsh and difficult environment that the standard prosthetic cover would be inadequate for the 
patient's needs. The health plan has stated that the device manufacturer and PDAC indicate that the requested 
Highlander Max foot is coded as L5981 (not L5980). Provided medical records do not clarify that the requested 
foot is correctly coded to meet Medicare criteria for coverage as medically reasonable and necessary. Provided 
medical records do not clarify that L5995 is not miscoded and is not unbundled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a protective outer surface covering (L5962), flex foot system 
(L5981), and heavy-duty feature (L5995) for a lower limb prosthesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) molecular test polymerase 
chain reaction (PCR) panel provided on March 14, 2023, and billed with codes 87481 x 5 and 87798 x 13. 
 
You asked the Plan to pay for the UTI molecular test 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 for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urinary tract infection (UTI) molecular test polymerase chain reaction (PCR) 
panel provided on March 14, 2023, and billed with codes 87481 x 5 and 87798 x 13.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 2, 2023, to July 
31, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that home health claims must be billed with one of the 
three Q codes (Q5001, Q5002, and Q5009), 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with the incorrect Q code. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered from July 2, 
2023, to July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on July 26, 2023, 
to August 03, 2023. 
 
You asked the Plan to waive the copayment for each office visit. You say that you saw the nurse practitioner on 
this date of service and should only have a $5.00 copay for each visit. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for each office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 $80 ($40 copayment x 2 visits 
= $80). Therefore, we decided that the Plan does not have to waive the copayment for each office visit provided 
on July 26, 2023, to August 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic Assay (0345U) provided on July 
14, 2023. 
 
You asked the Plan to pay for the Genesight Psychotropic Assay. You say that this service is covered by 
Medicare. The Plan denied your request. The Plan says the medical record does not indicate which drugs are 
being considered to be started or switching too, except for a dose 
adjustment to Prozac, or that non-genetic factors have been considered, the testing is not considered reasonable 
and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
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 Genesight Psychotropic Assay. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that the enrollee has 
responded somewhat however there is no documentation of this patient undergoing augmentation therapy. 
Utilizing the information from the records provided and utilizing LCD L38394, the GeneSight Psychotropic 
Assay is not considered reasonable or medically necessary as this patient has not had documentation of the 
diagnosis provided and non-genetic factors were considered as the patient has shown slight improvement, but 
no augmentation was performed. 
 
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 Genesight Psychotropic Assay have not been met. Therefore, we decided 
that the Plan does not have to pay for the Genesight Psychotropic Assay (0345U) provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on July 11, 2023. 
 
You asked the Plan to pay for a new patient office visit. You say that this is supported in the records. 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 a new patient office visit 
provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on July 12, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that you were not aware that the 
provider was out-of-network. 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 an office visit, and 
related services provided on July 12, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0429, A0425) provided on April 2, 2023. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
are supported for separate payment. The Plan denied your request. The Plan says that the payment for these 
services is included in the inpatient payment to the hospital. 
 
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. We find that the Plan has provided no documentation to support that these 
services would be included in the payment to any facility. There is no evidence that the enrollee maintained 
inpatient status with one facility on the date in question or that the enrollee was transported to a different 
building within the same hospital/facility group. These services are not supported as being inpatient 
transportation. The Plan's denial is not substantiated, and these services should be separately payable based on 
the documentation provided. Therefore, we decided that the Plan has to pay for ambulance services (A0429, 
A0425) provided on April 2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental extractions. 
 
You asked the Plan to pre-approve the dental extractions. You say that you would like to request 
reconsideration of the denied dental services and that the services requested are medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Therefore, 
we decided that the Plan does not have to pre-approve the dental extractions.
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 August 31, 2023, and billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 
87563, 87591, 87661, 87481, 87651 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 per Local Coverage Article (LCA) A58726, this type of testing must be 
billed as a single unit of service with a single code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on August 31, 
2023, and billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 
87481, 87651 and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 2, 2023. 
 
You asked the Plan to pay for the billed service. You say that the testing was needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the billed service have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for procedure code 83789 billed for date of service June 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you 
received a notice stating that the CT scan was covered. If you knew there was a copayment, you would not 
have had this done. 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 $190 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $190 copayment for the computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is 
less than the standard copayment, you only owe $93.48. Therefore, we decided that the Plan does not have to 
waive the copayment for the computed tomography (CT) scan provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by codes 01392, 99100, and 
99140 performed on date of service May 6, 2023. 
 
You asked the Plan to pay for 01392, 99100, and 99140. You say that 01392, 99100, and 99140 should be paid 
as billed because they are supported in the documentation and were billed correctly. The Plan denied your 
request. The Plan says 01392 is denied because it is not supported in the documentation. 9100 and 99140 are 
denied because they are considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that the Physician Fee Schedule Status Indicator B means 
that payment for covered services is always bundled into payment for other services not specified.  
 
We looked at the file and Medicare rules. Regarding code 01392, the case file does not contain any anesthesia 
records. The case file shows documentation that the Plan requested records for appealed anesthesia code 01392, 
but the documentation sent by the provider only contains records for other procedures and services. Therefore, 
we are unable to verify 01392. We also confirmed that procedure codes 99100 and 99140 both have a status 
indicator of B on the Physician Fee Schedule. This means that procedure codes 99100 and 99140 are not 
separately payable. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of code 01392 have been met. We decided the Medicare rules for 
coverage of codes 99100 and 99140 have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services described by codes 01392, 99100, and 99140 performed on date of service May 
6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the magnetic resonance angiogram 
provided on June 28, 2023. 
 
You asked the Plan to reduce the copayment for the magnetic resonance angiogram. You say that you should 
only have a $100 copayment. 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 $180 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $180 copayment for the magnetic resonance angiogram. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 reduce the copayment for the magnetic resonance angiogram provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of residual tooth roots (D7250 x4) on July 
19, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 the requested item or service was exhausted on date of service July 19, 2023. This 
means that you are also responsible for the full cost of D7250 for tooth #29 and #31. In addition, you are only 
responsible for the difference between the billed and allowed amount of the downgraded codes for tooth #25 
and #26. Therefore, we decided that the Plan does not have to pay for surgical removal of residual tooth roots 
(D7250 x4), provided on July 19, 2023.