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

 
We decided that the Plan has to pay for procedure code G0480. We decided that the Plan does not have to pay 
for procedure code 83789.  
 
You asked the Plan to pay for procedure codes G0480 and 83789 billed for date of service July 26, 2023. You 
say that you have billed the services at issue correctly. The Plan says that rules for payment have not been met. 
 
We decided that the Plan has to pay for procedure code G0480.  
 
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 G0480 was designated as a column II code to column I code 80307 
on the date of service at issue. CMS has withdrawn the edit between these codes, and the withdrawal is 
retroactive. Based on this information, we decided that Medicare rules for coverage of code G0480 have been 
met. Therefore, we decided that the Plan has to pay for procedure code G0480.  
 
We also decided that the Plan does not have to pay for procedure code 83789. 
 
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 procedure code 83789 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. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for stereotactic body radiation therapy (SBRT)
(77370, 77373, and 77470) for the enrollee.

You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal, this treatment
was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not
met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the medical records
show the enrollee has "seemingly oligometastatic cancer of unknown primary to the L4 vertebral body". The
Maximus review stated that SBRT is reasonable for metastatic lung, liver, adrenal, or kidney lesions per expert
opinion.

However, the enrollee does not have a tumor either metastatic to or from the lung, liver, adrenal, or kidney. The
Plan states there is no published data on which to draw a conclusion about SBRT to the spine for metastatic
cancer of an "unknown primary".

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only covers services
demonstrated to be medically necessary by the medical records. Based on the enrollee's diagnosis,
there is insufficient information in the record to determine if SBRT is covered by medically necessary in this
case. Therefore, we decided that the Plan does not have to provide coverage for stereotactic body radiation
therapy (SBRT) (77370, 77373, and 77470) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(IONM) provided on March 21, 2022. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it 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 pay for continuous intraoperative neurophysiology 
monitoring. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the conflicting evidence to date and the overarching 
consensus that further study is necessary to evaluate the use of IONM in lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous intraoperative neurophysiology monitoring have not been met. 
Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology 
monitoring (IONM) provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 13, 2023. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says this dental work has been correctly denied. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on June 
13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 8, 2023, to August 14, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service August 8, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on August 8, 2023, to August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 11, 2023. 
 
You asked the Plan to pay for an office visit. You say that you were unaware 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 an office visit provided 
on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered from May 24, 2021, to
December 8, 2021.

You asked the Plan to pay for these services. You say that the services are only dental in nature due to several
face fractures and should be covered. The Plan denied your request. The Plan says the services are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

We looked at the file and Medicare rules. The previous determination stated that the Plan must pay for the
services because they did not provide the correct Schedule of Cost Sharing; however, the Plan submitted
documentation clearly showing that a 2021 Schedule of Cost Sharing and Evidence of Coverage were
submitted with the appeal. The services you are asking the Plan to pay for involve the care, treatment, filling,
removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services
that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the
dental services rendered from May 24, 2021, to December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this facility is the setting where you can 
receive the highest quality of care. The Plan denied your request. The Plan says when you are ready to leave 
the hospital, you can receive the care you need in another setting such as a skilled nursing facility (SNF) or an 
inpatient rehabilitation facility (IRF). 
 
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 record indicates that you are improving but still requires acute care services 
before transitioning to a lower level of care. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving 
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be recommended. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95249 billed for date of service August 29, 
2023. 
 
You asked the Plan to pay for procedure code 95249. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not separately payable as billed. 
 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 outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 3 for CPT code 95249. This means there is only a 
technical component for the CPT code. Based on this information, we decided that Medicare rules for coverage 
of procedure code 95249 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95249 billed for date of service August 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
July 10, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that there are no bundling edits for 
these codes. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are 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 codes 20930 and 20936 billed for date of service July 10, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says that you have already used 100 days of inpatient SNF services for the
current benefit period. Maximus overturned the Plan's denial based on medical necessity. The Plan requested a
reopening and stated the denial was not based on medical necessity but that you have exhausted the SNF
benefit. The Plan is correct in this case. The rules say that enrollees are covered for up to 100 days of skilled
care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care
and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that you received 100 days of SNF care during the benefit period from March 21, 2023, through
April 8, 2023, April 14, 2023, through May 4, 2023, June 12, 2023, through July 26, 2023, July 28, 2023,
through August 14, 2023. The Plan has covered 100 days of SNF care.

Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the Plan will continue to provide cover medically 
necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an 
alternate level of care. 
 
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 record indicates that the enrollee has had a complicated post-operative course and 
still has ongoing acute medical issues, requiring acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules are not satisfied. The requested service cannot be recommended. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services (99458, 99457) and chronic care management services (99490) provided on July 31, 2023. 
 
You asked the Plan to pay for remote physiologic monitoring treatment management services (99458, 99457) 
and chronic care management services (99490). You say that the services should be covered. 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 remote physiologic 
monitoring treatment management services (99458, 99457) and chronic care management services (99490) 
provided on July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 15, 2023, to August 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the 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 $275 
copayment for inpatient hospital care. 
 
You have been asked to pay a $275 copayment for the 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 $550 for the inpatient hospital stay ($275 copayment 
x 2 days = $550). 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 the inpatient hospital stay provided on August 15, 2023, to 
August 17, 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 February 2, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that diagnosis code K56.41 has an Excludes1 note in relation to diagnosis code 
group K59. This means that diagnosis codes K56.41 and K59.04 cannot be reported together. 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 procedure code 99232 billed for date of service February 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service June 
29, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was transported twice on the same 
day. The Plan denied your request. The Plan says the services are considered part of the inpatient admission. 
 
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 file shows that the enrollee was an inpatient at the time the services at issue were provided. The 
transportation codes A0425 and A0428 were billed with modifier HH, indicating the enrollee was transported 
from one hospital facility to another hospital facility. The payment for transportation is bundled into payment 
for the inpatient services. 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 the ambulance 
transportation billed for date of service June 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Namenda XR. 
 
You asked the Plan to pre-approve the medication. You say that Namenda XR is necessary in treating the 
enrollee's condition. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the use of Namenda XR.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.