Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4221 and A4222 billed for date of service 
April 18, 2023, to April 24, 2023.  
 
You asked the Plan to pay for procedure codes A4221 and A4222. 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 codes A4221 and A4222 is 0. The MAI value for this code is 3. You billed 1 
unit of code A4221 and 7 units of code A4222, 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 A4221 
and A4222 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
A4221 and A4222 billed for date of service April 18, 2023, to April 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an intrauterine device (IUD) and 
insertion of etonogestrel implant system. 
 
You asked the Plan to pre-approve contraceptive services. You say that the enrollee currently has an IUD for 
contraception management. You say that it is due to be changed. You also say that other forms of birth control 
are not recommended for the enrollee's condition. The Plan denied your request. The Plan says contraceptive 
devices or medications are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested services are primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules 
for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-
approve the removal of an intrauterine device (IUD) and insertion of etonogestrel implant system.
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 LTACH services. You say that the enrollee needs LTACH services to 
optimize her to be able to safely transfer to a lower level of care or home. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient care and is currently unstable for transfer to an 
LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at a LTACH that the enrollee requires, that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH admission is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chromosome analysis; count 20-25 cells (88264) 
provided May 18, 2023. 
 
You asked the Plan to pay for the laboratory testing.. You say that please let the attached documentation serve 
to support medical necessity of the testing performed. The Plan denied your request. The Plan says the 
enrollee's diagnosis does not meet criteria of medical necessity.  
 
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 the laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee had the diagnosis of monoclonal gammopathy of 
undetermined significance (MGUS). The diagnosis of MGUS is not an approved reasonable or necessary 
diagnosis for cytogenetic studies per the NCD criteria. The review has determined that the medical records 
provided did not meet the medically necessary requirements for Medicare coverage. 
 
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 laboratory testing. have not been met. Therefore, we decided that the Plan 
does not have to pay for the chromosome analysis; count 20-25 cells (88264) provided May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87640, 87481, 87798, 87653, 87086 
and 81003) billed for date of service October 23, 2022. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this claim was not submitted in accordance with Medicare billing 
guidelines. 
 
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 panel (87640, 87481, 87798, 87653, 87086 and 81003) billed for 
date of service October 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an alignable system described by code
L5910 for the enrollee.

You asked the Plan to provide coverage for an alignable system described by code L5910. The Plan denied
your request. The Plan says this component was requested in error. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that this item
called an "alignable system" is incompatible with a "non-alignable" preparatory socket and therefore cannot be
approved as requested.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The issue was not medical necessity but the fact that
the request was for an item not compatible with the enrollee's other prosthetic components. Therefore, we
decided that the Plan does not have to provide coverage for an alignable system described by code
L5910 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on July 27, 2023. 
 
You asked the Plan to pay for the fungal infection PCR panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says that the guidelines state that fungal infection of the nail 
(tinea unguium or onychomycosis) can be verified by direct microscopic examination with potassium 
hydroxide, fungal culture of desquamated subungual material, or fungal stain of a nail clippings fixed in 
formalin. 
 
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 the fungal infection PCR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the current standard of care for investigation of onychomycosis in a 
toenail is to perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, 
and specific. It is unclear as to why this enrollee's right hallux nail specimen required PCR testing when other 
less expensive and efficacious lab tests (KOH and fungal culture) are available. Therefore, it is my opinion that 
the requested PCR testing of this enrollee's right hallux toenail was not medically reasonable or necessary. 
 
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 fungal infection PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel provided on July 
27, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ropinirole HCL. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Ropinirole HCL.   
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 17, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until June 22, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service July 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that these lab services are covered by Medicare. 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 billed for date of service 
July 18, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 81003. We decided that the Plan does not have to pay 
for procedure codes 87640, 87481, 87798, 87653.  
 
You asked the Plan to pay for the lab testing billed for date of service March 1, 2023. You say that the testing 
was provided for the enrollee's medical condition. The Plan says that one code must be submitted for the panel. 
 
We decided that the Plan has to pay for procedure code 81003.  
 
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 81003 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy. 
 
We find that CPT code 81003 is supported in the medical record. The records show that a urinalysis was 
ordered and provided separate from the panel test. Based on this information, we decided that Medicare rules 
for coverage have been met. Therefore, we decided that the Plan has to pay for procedure code 81003 billed for 
date of service March 1, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87640, 87481, 87798, 87653. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The records show that a urinary tract infection panel was provided. We looked at the file and Medicare rules. 
This NGS panel was not billed with a single code as required. 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 87640, 87481, 87798, 87653 billed for date of service March 1, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for Hyalgan. 
  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Hyalgan. Our reviewer says that the 
requested drug is not recommended. Our physician reviewer found that the records do not document the trial 
and failure of a three-month course of conservative therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0431 billed for date of service March 24, 
2023, to April 23, 2023.  
 You asked the Plan to pay for procedure code E0431. You say that the codes should not be considered as 
multiple units. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code E0431 is 1. The MAI value for this code is 2. You billed 31 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code E0431 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code E0431 billed for date of service March 24, 2023, to April 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99219 billed for date of service June 25, 2021. 
 
You asked the Plan to pay for code 99219. You say that the medical records show the necessity of the services 
rendered. The Plan denied your request. The Plan says you billed the wrong Place of Service code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99219 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99219 billed for date of service June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revenue code 0761 billed for dates of service August 2, 2023, 
to August 9, 2023. 
 
You asked the Plan to pay for the billed service. You say that revenue code 0761 occurred within 24 hours of 
the admission. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the treatment room services were provided within 3 days of a 
hospital admission. A modifier was not appended to identify services not related to the admission. Based on 
this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for revenue code 0761 billed for dates of service 
August 2, 2023, to August 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85007 and 85008 billed for date of service 
July 17, 2023.  

You asked the Plan to pay for procedure code 85007 and 85008. You say that the services were medically 
necessary. The Plan denied your request. The Plan says payment for code 85007 and 85008 is bundled into 
payment for code 85025. 
 
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 codes 85007 and 85008 are column two codes to column one code 85025 
with a modifier indicator of 0. The column two codes are therefore not payable. 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 85007 and 85008 billed for date of service July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81433 billed for date of service June 28, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that sensitivity and specificity of the testing has been 
proven in studies. The Plan denied your request. The Plan says this was not a separate and distinct test. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. Code 81433 was not billed with a modifier indicate that a separate and 
distinct lab procedure was provided. Based on this information, we decided that Medicare rules for coverage of 
the billed testing have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 81433 billed for date of service June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary for post-surgical swelling. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation to and from surgery 
appointments. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation to and from surgery 
appointments.