Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an interim partial denture (D5820).

You asked the Plan to provide coverage for interim partial denture (D5820). You say that at the time of the
appeal, the requested interim denture was medically necessary. The Plan denied your request. The Plan says at
the time of the appeal, interim dentures were not covered under the Plans dental benefit. The IRE upheld the
Plans denial. On January 19, 2021, you requested an ALJ hearing. On February 5, 2021, the ALJ sent you a
letter indicating the case was being remanded back to the IRE due to missing documentation that had been
requested and not received by the ALJ. However, the IRE did not receive notice of the remand until January 4,
2024.

After a reopen review of this appeal, we maintain that the documentation submitted in the case file was
sufficient in content to make a substantive decision. The Plan provided clear denial notification of your appeal
and the Dental Plan's Office Reference Manual (ORM) showing the specific coverage criteria for dentures.

The ALJ remanded the case back to us stating there was documentation not contained within the case file that
they required for review. However, the ALJ is well within their right to request this documentation directly
from the health plan and does not appear to have done so. While the ALJ is within their right to remand the
case back to the IRE, our decision remains unchanged, and no further reconstruction of the record is needed.

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, at the time of the appeal, an interim denture was not a covered
item under the Plan dental benefit. Therefore, we decided that the Plan does not have to provide coverage for
an interim partial denture (D5820).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 19, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that their original decision to deny payment was correct. 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 an office visit provided on September 19, 2023, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 16, 2023, billed with 
codes 87481, 87640, 87651, 87653 and 87798. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says panel testing should be billed using one Current Procedural 
Terminology (CPT) code on the claim. 
 
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 laboratory services provided on August 16, 2023, billed with codes 87481, 
87640, 87651, 87653 and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 rendered on September 13, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says specimen validity testing is not 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 services 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 rendered on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a total electric hospital bed.

You asked the Plan to provide coverage for a total electric hospital bed. You say that at the time of the appeal,
a total electric hospital bed was medically necessary. The Plan denied your request. The Plan says Medicare
does not cover a total electric hospital bed. Maximus upheld the Plans decision on June 15, 2020. On June 25,
2020, you requested an ALJ hearing. On July 7, 2021, the ALJ sent you a letter stating they issued a remand of
this case back to the IRE. However due to issues at OMHA, the IRE was never notified of this remanded
decision until January 4, 2024, hence the late response.

The ALJ remanded this case back to us because they had technical issues downloading documentation in the
shared file system used to access case files. The ALJ states they tried several times to have this resolved with
no success and remanded the case back to the IRE. Unfortunately, this is not a reason to remand a case. The
IRE has no control over any technical issues the ALJ has retrieving their case files via the shared document
system. After review of the original case file, our decision remains unchanged. The Plan must follow Medicare
rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may
be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided
that the Plan does not have to provide coverage for a total electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0242U) provided on July 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 0242U is not supported in the medical record. Specifically, the claim was billed with an 
unspecified laterality diagnosis code (C34.90). The records support right-side laterality. There is a more 
appropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (0242U) 
provided on July 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy (92507) provided on September 20, 2023. 
 
You asked the Plan to pay for speech therapy. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules list the ICD-10-CM codes support medical necessity and 
provide coverage for select CPT/HCPCS codes, including code 92507. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of speech therapy have not been met. Specifically, the diagnosis codes reported on the claim are not 
listed in the rules as codes that support medical necessity for the service at issue.  
  Therefore, we decided that the Plan does not have to pay for speech therapy (92507) provided on September 
20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99349-25 rendered on July 18, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the clinical does not show a significant different, separately identifiable evaluation and 
management (E&M) service. 
 
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 99349 is "Home or residence visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 40 minutes must be met or exceeded." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report documents 
the chief complaint as an open wound, for which a wound assessment was done. The record does not include 
documentation of a significant, separately identifiable evaluation and management (E/M) service above and 
beyond that would be associated with the wound care provided. CPT 99349 with modifier 25 cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99349-25 rendered on July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 31, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 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 laboratory services rendered on August 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 12, 2023, billed with 
code 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  

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. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 12, 2023, billed with code 81272.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomographic angiography 
(CTA) scan provided on July 05, 2023. 
 
You asked the Plan to waive the copayment for the computed tomographic angiography (CTA) scan. You say 
that you are on a fixed income and cannot afford to pay 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the computed tomographic angiography (CTA) 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. Therefore, we decided that 
the Plan does not have to waive the copayment for the computed tomographic angiography (CTA) scan 
provided on July 05, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for procedure code 97010. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 97010 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services described by code 
99232 billed on June 20, 2023, and June 21, 2023. 
 
You asked the Plan to pay for the evaluation and management services. You say that the evaluation and 
management services should be paid as billed because they are supported in the documentation. The Plan 
denied your request. The Plan says the evaluation and management services are denied because they are not 
supported in the provided documentation. 
 
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. 
 
We looked at the file and Medicare rules. In this case, we have confirmed that the provided medical records do 
not include any supporting documentation or an evaluation and management note for either date of service in 
question, June 20, 2023, and June 21, 2023. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the evaluation and management 
services have been met. Therefore, we decided that the Plan does not have to pay for evaluation and 
management services described by code 99232 billed on June 20, 2023, and June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0676, 
trunk appliance coded E0656, and half leg appliance coded E0673 billed for October 4, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 and trunk appliance billed with code E0656 are also not covered. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0676, trunk 
appliance coded E0656, and half leg appliance coded E0673 billed for October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dermatology office visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the office visits. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says the services were not approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
dermatology office visits to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0391U) provided on September 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0391U) provided on 
September 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel billed with codes 87481, 
87500, 87653, and 87798 for date of service June 12, 2023. 
 
You asked the Plan to pay for the urinary tract infection panel billed with codes 87481, 87500, 87653, and 
87798. 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 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 panel billed with codes 87481, 87500, 87653, and 
87798 for date of service June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on August 1, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.   
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
September 18, 2022, to December 28, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have paid all your 
bills and should not owe anything else. You feel you should be paid back for some of these copays. 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 $290 
copayment for inpatient hospital care.  
You have been asked to pay a $290 copayment for an inpatient hospital stay. 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. You have been asked to pay a total of $1,450 for the inpatient hospital stay ($290 
copayment x 5 days = $1,450). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
September 18, 2022, to December 28, 2022.