Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 81231, 81232, 81335, and 
81306. We decided that the Plan does not have to pay for the services described by procedure codes 81225, 
81226, 81227, 81240, 81241, and 81328.  
 
You asked the Plan to pay for the lab testing billed for date of service August 7, 2023. You say that the 
documentation supports the services billed. The Plan says that one code must be submitted for the panel. 
 
We decided that the Plan has to pay for the services described by procedure codes 81231, 81232, 81335, 
and 81306.  
 
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 codes 81231, 81232, 81335, and 
81306.  
 
We also decided that the Plan does not have to pay for the services described by procedure codes 81225, 
81226, 81227, 81240, 81241, and 81328. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a combined cardio and pharmacogenetic test panel was provided. We looked at the file and 
Medicare rules. This was an NGS panel that was not billed with a single panel code as required. We looked at 
this physician's review, the file, and Medicare rules. 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 services 
described by procedure codes 81225, 81226, 81227, 81240, 81241, and 81328. 
 
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 pay for the treatment of a root canal obstruction (D3331) provided 
on September 29, 2023. 
 
You asked the Plan to pay for the treatment of a root canal obstruction. You say that you are still in severe pain, 
and they have only temporarily glued the cap on, they refuse to fix it. You also say that you are now in debt for 
the treatments that your insurance did not cover. The Plan denied your request. The Plan says this service is not 
a covered expense under your dental plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
treatment of a root canal obstruction (D3331) provided on September 29, 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 medical records provided support the 
need for care in an LTACH. The Plan denied your request. The Plan says services can be provided in a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 a 76-year-old male with diabetes, hypertension, end-stage kidney 
disease with hemodialysis dependence, and coronary artery disease who was admitted from his skilled nursing 
facility with respiratory failure from influenza B; he required intubation, tracheostomy, and PEG tube placement. He is on pressure support on a PEEP of 5 an 30% FiO2. He is unlikely to require more than 25 days 
in LTACH. 
 
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: Favorable

 
We decided that the Plan has to pay for the AlloSure Heart testing provided on September 29, 2022. 
 
You asked the Plan to pay for the AlloSure Heart testing. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services were provided well beyond the 55-day requirement. 
 
The Plan must follow Medicare rules. Medicare rules say that AlloSure Heart is covered for patients at least 
55 days post-transplant in conjunction with standard clinical assessment.  
 
We looked at the file and Medicare rules. Review of the file shows that the rules state that AlloSure Heart 
testing is covered for enrollees who are at least 55 days post- transplant. The enrollee had a heart transplant in 
2015. Since the rule does not give a limit of days after transplant and at least 55 days had passed since the 
enrollee received a heart transplant, the documentation does not support that the enrollee did not meet criteria 
for the testing rendered. No other denial rationale was provided. Therefore, the Plan did not substantiate their 
denial. Based on this information, we decided that Medicare rules for coverage of the AlloSure Heart testing 
have been met. Therefore, we decided that the Plan has to pay for the AlloSure Heart testing provided on 
September 29, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture - maxillary (D5130) provided on July 11, 
2023. 
 
You asked the Plan to pay for immediate denture - maxillary. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
immediate denture - maxillary (D5130) provided on July 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care/detoxification from May 1, 2023, 
through May 5, 2023. 
 
You asked the Plan to pay for inpatient psychiatric care/detoxification from May 1, 2023, through May 5, 2023. 
You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee 
does not appear to have acute withdrawal or mental health symptoms that require this level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care/detoxification 
from May 1, 2023, through May 5, 2023. Our reviewer says that the enrollee does not meet the criteria for 
treatment in an acute inpatient mental health treatment from May 1, 2023, through May 5, 2023. Our physician 
reviewer found the enrollee did not require inpatient psychiatric care/detoxification from May 1, 2023, through 
May 5, 2023. as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care/detoxification from May 1, 2023, through May 5, 
2023, have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric 
care/detoxification from May 1, 2023, through May 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed 
conservative treatments without relief. The Plan denied your request. The Plan says the intracept procedure is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease or 
stenosis, and the cause of pain is not clear. 
 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care from June 16, 2023, through June 
20, 2023. 
 
You asked the Plan to pay for inpatient psychiatric care from June 16, 2023, through June 20, 2023. You say 
that the services were medically necessary. The Plan denied your request. The Plan says the services were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from June 16, 
2023, through June 20, 2023. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment from June 16, 2023, through June 20, 2023. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment from June 16, 2023, through June 20, 2023, 
as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It 
did not appear that active treatment was taking place beyond the date in question. It did not appear that the 
services for the dates in question were reasonably expected or medically necessary to improve the enrollees 
condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 16, 2023, through June 20, 2023, have not 
been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric care from June 16, 
2023, through June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) A4649, 73130-TC-RT-59, 96374-59, and 
96375-59 billed for date of service August 27, 2023. 
 
You asked the Plan to pay for procedure code(s) A4649, 73130-TC-RT-59, 96374-59, and 96375-59. You say 
that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says codes 73130-
TC-RT-59, 96374-59, and 96375-59 are included in the facility payment and are not separately payable. Code 
A4649 has a status indicator P and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 73130-
TC-RT-59, 96374-59, and 96375-59. Procedure code A4649 has a status indicator P and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of procedure codes A4649, 
73130-TC-RT-59, 96374-59, and 96375-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) A4649, 73130-TC-RT-59, 96374-59, and 96375-59 billed for date of service 
August 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 11, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have been a patient of this provider for the last 
20 years. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) 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 office visit provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames and the single vision lens provided on 
September 26, 2023. 
 
You asked the Plan to pay for the deluxe frames and the single vision lens. You say that you had a routine eye 
examination for reading glasses and you were not aware you would have to pay over $417. The Plan denied 
your request. The Plan says the claim processed correctly. 
 
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 has a $100 benefit that goes towards the purchase and fitting of eyeglasses and pair of 
lenses. The Plan pays for one routine eye examination every year. 
 
We looked at the file and the Plan's rules. Specifically, the plan deducted $100 off the retail price of the 
eyewear. Please note, the record shows the Plan paid for the eye examination. Based on this information, we 
decided that the Plan's rules for coverage of the deluxe frames and the single vision lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the deluxe frames and the single vision lens 
provided on September 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76700) provided on August 31, 
2023. 
 
You asked the Plan to pay for an abdominal ultrasound (76700). You say that you thought the provider was in-
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 abdominal ultrasound (76700) provided on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 7, 2022, and
September 8, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says these services required prior authorization and no prior authorization
was on file. Maximus overturned the Plans denial because a Plan contract was not submitted for review. The
Plan requested a reopen and provided the Plan contract for review.

The Plan is correct in this case. 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 Plan had network
providers available who could provide the services at issue in this appeal. The enrollee did not have prior
authorization for out of network services. Therefore, we decided that the Plan does not have to pay for the
office visit provided on September 7, 2022, and September 8, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on September 20, 
2023. 
 
You asked the Plan to pay for the prophylaxis. You say that you feel this service should be paid. The Plan 
denied your request. The Plan says your benefit for the requested 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. The record 
shows your benefit for the requested service was exhausted on dates of service January 18, 2023, and May 15, 
2023. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on 
September 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 85025, 84443, 80048, 83036, and 
80061 billed for date of service April 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the pathology services were done in the lab 
setting. The Plan denied your request. The Plan says the codes are not payable. 
 
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 find that CPT codes 36415, 85025, 84443, 80048, 83036, and 80061 are not supported. The codes at issue 
are not covered pathology services provided at an independent laboratory. The codes at issue are excluded from 
payment under the Physician Fee Schedule. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 36415, 85025, 84443, 80048, 83036, and 80061 billed for date of service April 5, 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.  
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
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.