Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided by an out-of-network 
(OON) provider on October 23, 2020. 
 
You asked the Plan to pay for the inpatient hospital services provided OON. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says there is no documentation of instability 
requiring the enrollee to stay for admission at the OON facility. The Plan says that there was an agreement for 
transfer to an in-network facility on October 23, 2020, at 7:42 AM. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital services provided 
OON. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee presented to the emergency room with abdominal pain and nausea. The enrollee was found to have 
gastroenteritis and mild colitis. She was admitted for persistent abdominal pain. The emergency room 
physician made arrangements to transfer to contracted facility. The treating physician did not document that the 
enrollee was not stable for transfer on the date of service in dispute. The enrollee was stable for transfer on the 
day and time the disposition decision was made.  
 
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 inpatient hospital services provided OON have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital services provided by an out-of-network (OON) 
provider on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the equipment is needed after hip surgery. 
The Plan denied your request. The Plan says the item is not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that it is medically necessary. The Plan 
denied your request. The Plan says the destruction by neurolytic agent of the genicular nerve requested does 
not meet the requirements for approval. 
 
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 pre-approve genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this therapy is considered experimental. It is the subject of ongoing clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and cone 
beam CT image capture (D0384) provided on May 13, 2023. 
 
You asked the Plan to pay for limited oral evaluation and cone beam CT. You say that this was medically 
necessary. The Plan denied your request. The Plan says these are not covered services. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for limited 
oral evaluation - problem focused (D0140) and cone beam CT image capture (D0384) provided on May 13, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested testing. You say that you need the test to protect your 
daughter and grandchildren. The Plan denied your request. The Plan says screening genetic testing is not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The requested testing is being requested solely for screening purposes. 
Medicare does not cover the testing solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on February 12, 2021, 
to March 30, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the physical therapy 
services provided on February 12, 2021, to March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitrectomy recovery chair you rented on March 13, 2023. 
 
You asked the Plan to pay for the vitrectomy recovery chair. You say that you required this equipment 
following vitrectomy surgery. The Plan denied your request. The Plan says you obtained this item from a 
provider who is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider from 
whom you received this equipment is not enrolled in the Medicare program. Therefore, we decided that the 
Plan does not have to pay for the vitrectomy recovery chair you rented on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization procedures. 
 
You asked the Plan to pre-approve cardiac catheterization procedures. You say that it is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 pre-approve cardiac catheterization procedures. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a stress test showed an ischemic response. The enrollee is asymptomatic. 
The enrollee has not been treated with anti-ischemic medications. Guidelines do not support a need for cardiac 
catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this enrollees clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization procedures have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cardiac catheterization procedures.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits. 
 You asked the Plan to pre-approve the home health skilled nursing services. You say that you still have an open 
wound due to an infection that still needs to be taken care of. You also say that you have not been released by 
the doctor. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing services. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
you do not have documented skilled nursing needs. You have an available caregiver, who is able to perform the 
required wound care. You do not appear to be homebound, as evidenced by your ability to attend wound care 
and appointments. As such, ongoing home health skilled nursing services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home visits provided on March 4, 2023, to March 
18, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON nursing home visits. You say that the enrollee was residing at a 
Nursing and Rehabilitation Center and the provider was not responsible to obtain authorization. You say that 
the assisted living facility is responsible to obtain authorization for all of their patients, which should also cover 
the medical treatments provided by this OON provider.  The Plan denied your request. The Plan says there is 
no coverage for non-participating providers without prior authorization.  
 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 services at issue in this appeal. The Plan did not pre-approve the OON 
services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, 
we decided that the Plan does not have to pay for nursing home visits provided on March 4, 2023, to March 18, 
2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided to the enrollee from August 12,
2021, to September 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billed criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information.
The Plan noted that the provider billed this service with a Bill Type 327 for "Home Health Agency Inpatient",
with code Q5001. Type of Bill code 327 (inpatient facility) cannot be billed with code Q5001, defined as care
in the home or residence.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate Type of Bill code. In this case,
this claim could not be paid as billed due to an error with the TOB code of 327, inpatient facility, and the site of
service code reported of Q5001, for home or residence. Medicare rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the
enrollee from August 12, 2021, to September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 27, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc allograft. 
 
You asked the Plan to pre-approve Via Disc. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the clinical value and effectiveness of this procedure in the setting or 
discogenic low back pain have not been demonstrated. 
 
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 pre-approve Via Disc. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term, peer-reviewed literature that shows Via Disc 
to be a safe and/or effective treatment for the enrollee's condition. Further studies are needed to demonstrate 
this has beneficial outcomes compared with conventional treatment.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Via Disc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Via Disc allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29540 billed for date of service July 6, 2023.  
 
You asked the Plan to pay for procedure code 29540. You say that the procedure was performed bilaterally. 
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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 29540 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 29540 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 29540 billed for date of 
service July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 25, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are 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 the urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation shows that the urine PCR panel exceeded the enrollee's needs. There is no 
documentation as to why it was 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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each remote device evaluation provided on 
April 14, 2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for each remote device evaluation. You say that you did not go into 
the office on these dates. 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 $25 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $25 copayment for each remote device evaluation. This item/service falls within 
the in-network specialist physician/practitioner services 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. The record shows this claims were approved and you are 
responsible for the cost share amounts. The total you owe is $50 ($25 copayment per service x 2 services = 
$50). Therefore, we decided that the Plan does not have to waive the copayment for each remote device 
evaluation provided on April 14, 2023, to May 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service July 20, 
2023. 
 You asked the Plan to pay for procedure code 64450. You say that this code should be separately allowed. The 
Plan denied your request. The Plan says payment for code 64450 is bundled into payment for code 00350. 
 
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 64450 
is a column II code to column I code 00350. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Please note that your appeal letter seems to claim that you billed this code with the 59 modifier (which, if 
supported by the medical records, would allow for separate payment).  However, the claim you submitted does 
NOT include the 59 modifier.  As a result, this decision is based on the claim submitted without this modifier. 
If you have since submitted a corrected claim with the 59 modifier, you may follow up with the Plan with any 
questions you may have about that corrected claim. Therefore, we decided that the Plan does not have to pay 
for procedure code 64450 billed for date of service July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 20, 2022.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct billing criteria. The Plan noted that the service was billed with an incorrect
place of service code. The claim was billed with a place of service (POS) 81, Independent Laboratory,
independent of an institution or a physician's office. An independent laboratory taking a sample in its
laboratory shows "81" as place of service. As Maximus noted, the tissue specimen was collected during a
surgical hospital procedure. The difference between the collection date and the received date confirms that this
was not taken by the laboratory directly. As Maximus noted, the tissue specimen was collected during a
surgical hospital procedure. Medicare Guidance Says: Medicare says services must be verified in the submitted
provider documentation. If an independent lab bills for services, the place where the sample was taken is
shown. POS code 81 is used to describe samples taken by the laboratory directly. An independent laboratory
taking a sample in its laboratory shows "81" as place of service.
If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses
the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campusoutpatient
hospital (POS code 22), respectively. Therefore, Medicare billing criteria were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim was denied due to an error with the POS code. Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
lab services provided to the enrollee on May 20, 2022.