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

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty. Our reviewer says that the 
enrollee does not meet coverage criteria. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on the enrollee's daily activities. Moreover, 
the magnetic resonance imaging does not corroborate the compression fracture is acute or subacute. In fact, it 
states "no acute compression is noted here or elsewhere." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) and topical application of 
fluoride varnish (D1206) provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you scheduled and appointment with a new 
dentist so you thought the services would be covered. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested D1110  but is limited to two of (D1110, D4346, D4910) per 12 month(s) per patient and D1206 but 
is limited to two of (D1206, D1208) per 12 month(s) per patient. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D1110 and D1206 on dates of service June 16, 2022, and December 14, 2022. 
Therefore, the requested services were exhausted on date of service March 30, 2023. Therefore, we decided 
that the Plan does not have to pay for prophylaxis - adult (D1110) and topical application of fluoride varnish 
(D1206) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens, the anti-reflective coating, the frames, the 
polarization, and the polycarbonate lens on March 10, 2023. 
 
You asked the Plan to pay for the lens, the anti-reflective coating, the frames, the polarization, and the 
polycarbonate lens. You say that you are allowed one pair of eyeglasses per year, yet you were only reimbursed 
$175 for the glasses. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 these services up to $175 for eyewear. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $175 allowance to the lens which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the lens, the 
anti-reflective coating, the frames, the polarization, and the polycarbonate lens have not been met. Therefore, 
we decided that the Plan does not have to pay for the lens, the anti-reflective coating, the frames, the 
polarization, and the polycarbonate lens provided on March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for continued coverage for an E0466 ventilator beyond
the three months approved.
You asked the Plan to provide coverage for this ventilator beyond the three months approved. The Plan says
while three months were approved for transition, continued coverage beyond the approval is not covered by
Medicare. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus
made the same decision the Plan made.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for ventilators. We asked our physician reviewer to carefully review the case file. Our physician reviewer
found a home ventilator is not medically necessary. The Plan has approved three months to allow transition to a
bilevel positive airway pressure (BiPAP).
The home ventilator is currently being used in the average volume-assured pressure support (AVAPS) mode,
which can be delivered with BiPAP and therefore is not covered by Medicare. We looked at this physician's
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of
this ventilator beyond the three months approved by the Plan have not been met. Therefore, we decided that the
Plan does not have to provide coverage for continued coverage for an E0466 ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Freestyle Libre 14 continuous glucose
monitor (CGM) system for the enrollee.
You asked the Plan to provide coverage for this equipment. You say that this equipment is medically necessary
for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial for no medical records in the file. This was done in error as the Plans case
file was clear they requested records to support the appeal, and none were received.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of this equipment have been met. Medical
records to support the enrollee meets the required criteria were not submitted. Therefore, we decided that the
Plan does not have to provide coverage for the Freestyle Libre 14 continuous glucose monitor (CGM) system
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits provided from August 18, 
2017, to February 3, 2020. 
 
You asked the Plan to waive the copayments for the office visits. You say that you were not told about the 
copayment change. 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 $10 
copayment for Medicare-covered physician services with a primary care provider.  
 
You have been asked to pay a $10 copayment for each office visit provided on August 18, 2017, September 18, 
2017, and February 3, 2020. You have been asked to pay a total of $30 ($10 copayment x 3 visits = $30). These 
items/services fall within the physician/practitioner services, including doctor's office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the office visits provided from August 18, 2017, to 
February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests billed with codes 87491 and 87591 for date 
of service January 27, 2023. 
 
You asked the Plan to pay for laboratory tests. You say that these services were necessary and were ordered by 
the enrollee's physician. The Plan denied your request. The Plan says these tests were not medically necessary. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory tests have been met. 
Specifically, the codes at issue are for Chlamydia trachomatis and Neisseria gonorrhoeae. These tests are not 
listed among those included in the providers urinary tract infection (UTI) panel with antibiotic resistance 
panel. Rather, these services are included in the sexually transmitted infection (STI) panel. However, the test 
requisition form provided shows no indication that the STI panel was requested by this provider. Therefore, we 
decided that the Plan does not have to pay for laboratory tests billed with codes 87491 and 87591 for date of 
service January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92921 billed for date of service March 9, 
2023. 
 
You asked the Plan to pay for procedure code 92921. The Plan denied your request. The Plan says procedure 
code 92921 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 92921 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92921 is not separately payable. 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 procedure code 
92921 billed for date of service March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2021, billed with 
codes 81230, 81408, 81291, 81335, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
should be paid.  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 
October 25, 2021, billed with codes 81230, 81408, 81291, 81335, and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies coded A6196 and A6219 billed for date 
of service July 28, 2022. 

You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or proof of delivery for the supplies at issue in this case. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for wound care supplies coded A6196 and A6219 billed for date of 
service July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210)
provided on November 30, 2022.
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the requested item or
service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and
submitted additional documentation.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record
shows your benefit for the requested item or service was exhausted on date of service April 8, 2019. Therefore,
we decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210)
provided on November 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the infectious agent drug susceptibility phenotype prediction using 
regularly updated genotypic bioinformatics (87900) provided on February 7, 2023. 
 
You asked the Plan to pay for infectious agent drug susceptibility analysis. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
coverage of this testing. 
 
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. In this case medical records were not provided to review medical necessity. The 
case file does not include documentation showing the Plan attempted to obtain this information. Without 
medical records we are unable to verify that the Plan denied this service correctly. Therefore, we decided that 
the Plan has to pay for the infectious agent drug susceptibility phenotype prediction using regularly updated 
genotypic bioinformatics (87900) provided on February 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Candida species, amplified probe technique (87481) provided on December 29, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the documentation does not support that any candida species was tested.  
 
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 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 laboratory service. Our reviewer found there is no 
documentation that support procedure code 87481 (infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique) was provided on December 29, 2022. Provided records in this 
case do not document any testing for Candida species (or any other fungal species).  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique (87481) provided on December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says that neither Medicare nor your plan 
covers this request. Medical studies haven't proven this service/item is helpful for the treatment of the enrollee's 
health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found despite the Plans assertions to the contrary, the fact is that Medicare has and does 
cover powered orthoses such as this on a case-by-case basis. Center for Medicare & Medicaid Services (CMS) 
specifically created billing codes for this technology several years ago in order to permit such individual 
coverage determinations. This technology is not experimental. In fact, it is generally accepted as part of the 
standard of care among the medical community specializing in the treatment of enrollees like this one precisely 
because it has been proven to be helpful for permitting functional restoration of chronically paretic upper 
extremities in a way that is usually not possible through other therapeutic alternatives. That reality is materially 
proven by the literature reviews attached to the July 18, 2023, appeal letter by Dr. Kovelman. This specific 
enrollees medical history (as best summarized in the record by Dr. Leavitts June 15, 2023, clinic note) 
supports her individual need for the requested powered orthosis. This request for this enrollee is fully compliant 
with the reasonable and necessary criteria found in Chapter 13 of the Program Integrity Manual. Therefore, 
L8702 is hereby approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthotic device have been met. Therefore, we decided that the Plan 
has to pre-approve a MyoPro orthotic device (L8702).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81227, 81231, 81232, 81291, 81306, 
81335, 81238) provided on December 16, 2022. 
 
You asked the Plan to pay for the laboratory services . You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
All genomic sequencing procedures and molecular multianalyte assays (example, CPT codes 81410-81471), 
many multianalyte assays with algorithmic analyses (example., CPT codes 81490-81599, 0004M-XXXXM), 
and many Proprietary Laboratory Analyses (PLA) (example, CPT codes 00011-1-XXXXU) are 
deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) analytic methods that simultaneously assay multiple 
genes or genetic regions. A provider/supplier shall not additionally separately report testing for the same gene 
or genetic region by a different methodology (example, CPT codes 81105-81408, 81479, 88364-88377). 
Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate payment for 
multiple methods to test for the same analyte. 8. If one laboratory procedure evaluates multiple genes using a 
next generation sequencing 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 CPT code. If no CPT code accurately describes the procedure performed, the 
laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or 
may report multiple individual CPT codes describing the component test results when medically reasonable 
and necessary. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing 
of procedures) and ordered by the physician who is treating the beneficiary and using the results in the 
management of the enrollee's specific medical problem. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (81227, 81231, 81232, 81291, 81306, 81335, 81238) provided on 
December 16, 2022.