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

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on February 14, 2023.  
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that this is covered by Medicare at the 
amount of $3873. 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 DEX Diagnostics Exchange shows that this testing is 
not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the 
DecisionDx-SCC testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
DecisionDx-SCC testing provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service January 9, 
2023.  You asked the Plan to pay for procedure code 88374. You say that these services were necessary and are 
supported in the medical record. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standard wheelchair provided on March 01, 2023. 
 
You asked the Plan to pay for a standard wheelchair. You say that the enrollee was not notified that this 
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 a standard wheelchair 
provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 16, 
2023. 
 You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 
is a column II code to column I code 99233. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 16, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at home visit provided on February 14, 2023. 
 
You asked the Plan to pay for an at home visit. You say that you depend on the facility staff to verify eligibility 
and to obtain authorization. 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 at home visit 
provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 21, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel that this service should be 
covered. 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the each covered 
visit or consultation in an outpatient location with a specialist 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 office visit provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 31, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 nursing facility visit 
provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on January 02, 2023. 
 
You asked the Plan to pay for wound care. You say that you are requesting reconsideration stating that the 
enrollee had some wounds which needed immediate professional care. 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 wound care provided on 
January 02, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service February 11, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 code 99284 is not payable as billed. Specifically, this service was billed with diagnosis code 
N77.1 (Vaginitis, vulvitis and vulvovaginitis in diseases). This diagnosis code is a manifestation code, which 
means the underlying condition should be sequenced first followed by the manifestation code. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99284 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99284 for date of service February 
11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair provided on April 01, 2023. 
 
You asked the Plan to pay for the wheelchair. You say that the wheelchair is 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 wheelchair provided 
on April 01, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay separately for procedure codes G0378, 71046, 93306, 93305, 
93041, 96374, and 96375 provided from November 15, 2022, to November 16, 2022. 
 
You asked the Plan to pay separately for procedure codes G0378, 71046, 93306, 93305, 93041, 96374, and 
96375. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that if a claim contains 
services that result in an Ambulatory payment classifications (APCs) payment but also contains packaged 
services, separate payment for the packaged services is not made since payment is included in the APC. The 
rules also state that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In 
addition, services that have a status indicator of Q3, the payment for these services is considered part of the 
composite Ambulatory Payment Classification (APC) rate, so no separate payment is made. 
 
We looked at the file and Medicare rules. Medicare says that unconditionally packaged services are identified 
in the OPPS Addendum B with status indicator of N and these services are not paid separately since payment is 
included in the APC. Code G0378 is identified with a status indicator of N. No separate payment can be made 
for this code.  
 
Additionally, codes 93005 and 93041 are STV-packaged services because they have a status indicator of Q1 in 
Addendum B- Outpatient Prospective Payment System (OPPS). These codes were billed on the same claim as 
code 99285. Code 99285 has a status indicator of V. This means that codes 93005 and 93041 are not separately 
payable in this scenario.  
 
In relation to code 71046, the rules say that for services that have a status indicator of Q3, the payment for 
these services is considered part of the composite Ambulatory Payment Classification (APC) rate, so no 
separate payment is made. This code has a status indicator of Q3, so it is included in the APC payment and no 
separate payment is due.  
 
Lastly, codes 93306, 96374, and 96375 are not separately payable. These codes are assigned a status indicator 
of S and were reported on the same claim as procedure code 99285, which has a status indicator of V. 
 
Therefore, we decided that the Plan does not have to pay separately for procedure codes G0378, 71046, 93306, 
93305, 93041, 96374, and 96375 provided from November 15, 2022, to November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the eye exam provided on January 5, 2023. 
 
You asked the Plan to waive the deductible for the eye exam. You say that there was a mix-up with your 
enrollment. 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. Your 
contract with the Plan says that there is a $675 deductible which applies to vision care. Your contract with the 
Plan also clearly says that you must pay a $45 copayment after meeting the deductible for in-network eye 
exams. 
 
The item or service you asked the Plan to waive the deductible for falls within the vision care benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $675 deductible which 
applies to vision care. This cost sharing is a contractual obligation that had not been met at the time the eye exam was received on January 5, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the eye exam provided on January 5, 2023.  
 
Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the Kansas City CMS Regional Office so that it can look into your enrollment question.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 28, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say the assisted living facility is 
responsible to obtain prior authorization for all of their patients. 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 home visit for 
evaluation provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital clinic visit provided on March 06, 2023. 
 
You asked the Plan to pay for the hospital clinic 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 the hospital clinic visit 
provided on March 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
July 25, 2022, to July 31, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not understand 
the copayment amount. 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 $275 
copayment per day, for days 1-5, each time you are admitted to an acute care hospital. 
 
 
 You have been asked to pay a $1100 copayment for the inpatient hospital stay ($275 x 4 days = $1100). This 
item/service falls within the inpatient hospital care 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 the inpatient hospital stay provided from July 25, 2022, to July 31, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for continuous glucose meter (CGM) supplies billed with code A4239 
provided on February 20, 2023. 
 
You asked the Plan to pay for the CGM supplies. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says that these supplies have a status indicator of P on the 
Physician Fee Schedule, so no separate payment is allowed. 
 
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 Plans sole rationale for denial in this case is because code 
A4239 has a status indicator of P on the Physician Fee Schedule. That may be true.  However, the Physician 
Fee Schedule and related value files are not applicable here.  These supplies are clearly items used with durable 
medical equipment (DME), shipped by a DME vendor.  As such, the DME fee schedule should have been used.  
The Plan has provided no evidence that the supplies at issue are not payable under the DME fee schedule.  The 
burden is on the Plan to show why its denial is correct.  By failing to address coverage under the DME fee 
schedule, we find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for 
continuous glucose meter (CGM) supplies billed with code A4239 provided on February 20, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination provided on March 22, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for radiologic examination. You say that the services should be covered. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for radiologic examination provided on March 22, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the cost share liability for the porcelain/ceramic dental crown (D2740) 
provided on March 16, 2023. 
 
You asked the Plan to waive the cost share liability for this dental item. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this dental 
item was paid for as the least costly method of treatment. 
 
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 stated that the dental crown provided in this case was 
paid for at the least costly method of treatment as a dental crown-porcelain fused to predominantly base metal 
(D2751). However, the Plan has not provided medical records to substantiate that the claim was processed 
appropriately due your medical needs. The Plan has not substantiated their denial; therefore, we must find in 
your favor. Therefore, we decided that the Plan has to waive the cost share liability for the porcelain/ceramic 
dental crown (D2740) provided on March 16, 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.