Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the transportation services provided on December 1, 2022. 
 
You asked the Plan to pay for the transportation services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that payment is included in the facility 
payment. 
 
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 has provided no documentation to support that these 
services would be or were already 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. These services are not supported 
as being inpatient transportation. The Plan's denial is not substantiated. The Plan has provided no other 
rationale for their denial of payment, so our decision is based on the lack of evidence that the enrollee 
maintained inpatient status on the date of service at issue. Therefore, we decided that the Plan has to pay for the 
transportation services provided on December 1, 2022.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 16, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of 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 an office visit provided 
on May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies billed under code K0554 and submitted under Claim A for November 4, 2022.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says a cancellation for this claim was submitted by you as the provider for code K0554. Maximus overturned the Plans denial for code K0553, which was the code presented in the case file. The Plan requested a reopen and noted that code K0553 was noted in error and code K0554 was the code under review.
The Plan notes while Claim A was in review by the Plan, on November 23, 2022, the provider submitted a cancellation claim showing their clear intention was to void or cancel Claim A.
The Plan is correct in this case. The Plan has established there was a clerical error in the original case file referencing code K0553. The Plan has also established that a cancellation was requested for payment of Claim A by the provider. Therefore, we decided that the Plan does not have to pay for diabetic supplies billed under code K0554 and submitted under Claim A for November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641, and 87500 billed for May 25, 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 procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not supported in the 
medical record. Specifically, the records show that a panel of testing was performed and there is a more 
appropriate singular code for the services. 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 
procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 billed for May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6402 billed for date of service April 10, 
2023. 
 
You asked the Plan to pay for procedure code A6402. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A6402 is considered bundled/excluded. 
 
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 A6402 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6402 is excluded/not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code A6402 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A6402 billed for date of service April 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
reader. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic low blood sugar episodes. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre continuous glucose monitor (CGM) reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal endoscopy provided on May 25, 2023. 
 
You asked the Plan to pay for the nasal endoscopy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nasal endoscopy 
provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each continuous positive airway pressure 
device and the humidifier provided on April 28, 2023, to May 28, 2023. 
 
You asked the Plan to waive the coinsurance for each continuous positive airway pressure device and the 
humidifier. You say that you do not know why you are paying more for the items in 2023. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each continuous positive airway pressure device and the 
humidifier. This item/service falls within the durable medical equipment and related 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. Therefore, we decided that 
the Plan does not have to waive the coinsurance for each continuous positive airway pressure device and the 
humidifier provided on April 28, 2023, to May 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 02, 
2022, to November 26, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this service 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 subsequent nursing 
facility care provided on November 02, 2022, to November 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on 
April 28, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home or residence visit 
for the evaluation provided on April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 15, 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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 laboratory services rendered on 
May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86870 billed for date of service May 4, 2023. 
 
You asked the Plan to pay for procedure code 86870. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the billed code is a statutory exclusion. 
 
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 86870 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 86870 is a statutory exclusion. Based on this information, we decided that Medicare rules for 
coverage of procedure code 86870 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 86870 billed for date of service May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87491, 
87563, 87640, 87653, 87798, 87641, and 87500 for March 30, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87491, 87563, 87640, 87653, 
87798, 87641, and 87500 for March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0423 billed for dates of service from June 
27, 2023, to June 29, 2023. 
 You asked the Plan to pay for procedure code G0423. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for procedure code G0423 is bundled into 
payment for code G0422. 
 
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, we have confirmed that code G0423 is a column II code to column I code G0422; however, G0423 
was billed with a modifier.  
 
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 procedure code G0423. Our reviewer says that procedure 
code G0423 does not meet criteria for payment. Our reviewer found that there is no documentation in the case 
record to support separate billing of code G0423. The testing was performed with exercise, so code G0422 is 
correct. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0423 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0423 billed for dates of service from June 27, 2023, to June 29, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lens fitting (92310) provided on June 18, 2023.  
You asked the Plan to pay for contact lens fitting (92310). You say that you received a letter stating the billed 
amount would not be covered. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. The requested service is excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover a $200 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses. The fitting and follow-up for contact lenses are 
excluded from this benefit. Based on this information, we decided that the Plan's rules for coverage of contact 
lens fitting (92310) have not been met. Therefore, we decided that the Plan does not have to pay for contact 
lens fitting (92310) provided on June 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
31, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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 $250 
copayment for outpatient surgery/ambulatory surgical center visit. 
 
You have been asked to pay a $250 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/ambulatory surgical center visit 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 waive the 
copayment for an outpatient surgery provided on March 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy services provided on March 27, 2023. 
 
You asked the Plan to pay for the chemotherapy services. You say that you are requesting reconsideration of 
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 the chemotherapy 
services provided on March 27, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Amvuttra. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found Amvuttra is approved by the Food and 
Drug Administration (FDA) for treatment of polyneuropathy of hereditary transthyretin-mediated amyloidosis 
in adults. The enrollee has no contraindications for the medication. Given the evidence of efficacy in the 
medical literature, Amvuttra is medically necessary and safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Amvuttra.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT) and acupuncture 
provided on June 20, 2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment (CMT) and acupuncture. You say that this 
service 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 chiropractic 
manipulative treatment (CMT) and acupuncture provided on June 20, 2023.