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

 
We decided that the Plan does not have to pay for laboratory services provided on May 21, 2021. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar 
or sacral; third and any additional level(s) provided on August 30, 2022.  
 
You asked the Plan to pay for a third level facet joint injection. You say that a third level facet joint injection 
was medically necessary. The Plan denied your request. The Plan says one to two levels, either unilateral or 
bilateral, are allowed per session per spine region. The provider did not provide evidence of unique 
circumstances for a third level with sufficient documentation of medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
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  a third level facet joint injection. Our 
reviewer says that the requested third level facet joint injection is not considered medically necessary. Our 
physician reviewer found that according to the coverage criteria, one to two levels, either unilateral or bilateral, 
are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be 
considered under unique circumstances and with sufficient documentation of medical necessity on appeal. In 
this case, the provider did not provide evidence of such a unique circumstance.  In this case, the review has 
determined that the coverage criteria have not been met. 
 
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 third level facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; third and any additional level(s) provided on August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an intense level of physical 
therapy provided in an IRF. The Plan denied your request. The Plan says the IRF services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for online digital assessment provided on January 24, 2023. 
 
You asked the Plan to pay for online digital assessment. You say that you say that the PCP referral is not 
required for COVID-19 related claims as it is declared a public health emergency. 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 online digital assessment 
provided on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on
August 26, 2022.
You asked the Plan to pay for the knee orthosis and sleeve. You say that this was prescribed by the enrollee's
primary care physician and that the enrollee's condition meets criteria for coverage. The Plan denied your
request. The Plan says the documentation requirements have not been met. Maximus overturned the Plan's
denial. The Plan requested a reopening and stated these services were not denied for medical necessity but for
administrative reasons.
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 proof of delivery. The packing slip and proof of delivery provided have
different tracking numbers and therefore cannot substantiate delivery was made. The record shows that the Plan
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the
Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on October 11, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you say that the assisted living facility was 
responsible for authorization. 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 rest home visit provided 
on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99153 and 92921 billed for date of service 
October 26, 2022. 
 
You asked the Plan to pay for procedure codes 99153 and 92921. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says these codes are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 99153. This means there is only a 
technical component for the CPT code. This code is not payable when furnished to patients in a hospital 
outpatient department. 
 
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 of procedure code 99153 and 92921 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99153 and 
92921 billed for date of service October 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 22, 2023. 
 
You asked the Plan to pay for home health services. You say that you say that the assisted living facility was 
responsible for authorization. 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 home health services 
provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of tooth #28 (D7210) and a partial
mandibular denture (D5214) for the enrollee.
You asked the Plan to pre-approve the extraction and partial mandibular denture. You say that your benefit for
the extraction has not been exhausted. The Plan denied your request. The Plan says your benefit for the
requested services have 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 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 extraction was exhausted on date of service February 25, 2020, and the partial
mandibular denture was exhausted on November 18, 2019. Therefore, we decided that the Plan does not have
to pre-approve the extraction of tooth #28 (D7210) and a partial mandibular denture (D5214) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 for date of service January 21, 2023. 
 
You asked the Plan to pay for procedure code 99222. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 We find that CPT code 99222 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee was in outpatient observation for this date of service. The claim is not payable as billed. Based 
on this information, we decided that Medicare rules for coverage of procedure code 99222 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222 for date of service January 
21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on August 24, 2022. 
 
You asked the Plan to pay for an ultrasound. You say that this was medically necessary and 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 an ultrasound provided 
on August 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for pembrolizumab injection provided on 
January 16, 2023. 
 
You asked the Plan to waive the coinsurance for pembrolizumab injection. You say that you cannot afford to 
pay the coinsurance for this visits. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for pembrolizumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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 coinsurance for 
pembrolizumab injection provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 16, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. 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 office visit provided on 
September 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 19, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this should be considered emergent, since the 
specimen being tested was bone marrow. 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 laboratory testing 
provided on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate maxillary denture and bone replacement graft 
(D5130, D7953) provided on August 9, 2022, to October 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 an 
immediate maxillary denture and bone replacement graft (D5130, D7953) provided on August 9, 2022, to 
October 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 08, 2022. 
 
You asked the Plan to pay for an office visit. You say that we are a new clinic and are not used to the billing 
process yet. 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 August 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99222, 93010, and 99153 billed for date of 
service September 26, 2022, to September 29, 2022. 
 
You asked the Plan to pay for procedure codes 99222, 93010, and 99153. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 99222 and 93010 is bundled into 
payment for other codes. Code 99153 is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99222 
is a column II code to column I code 92941. We have confirmed that code 93010 is column II code to column I 
code 92941. This claim has not been billed with an appropriate modifier to bypass the edit. 
 
The records indicate that this service was provided to the enrollee while an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there is only a 
technical component for the CPT code. Code 99153 cannot be paid if furnished to hospital inpatients or 
patients in a hospital outpatient department. 
 
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 codes 99222, 93010, and 99153 billed for date of service September 26, 
2022, to September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vertebral axial decompression, per session (S9090), 
office visit (99212), physical or manipulative therapy performed for maintenance rather than restoration 
(S8990), and the group therapeutic procedures (97150) provided from March 28, 2022, through October 10, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules say that Medicare does not cover 
chiropractic maintenance care. Additionally, the Plans contract provides supplemental coverage for spine  
x-rays and chiropractic radiology services.  
 
The records show that the services at issue are not covered by Medicare or the Plan. Therefore, we decided that 
the Plan does not have to pay for the vertebral axial decompression, per session (S9090), office visit (99212), 
physical or manipulative therapy performed for maintenance rather than restoration (S8990), and the group 
therapeutic procedures (97150) provided from March 28, 2022, through October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on April 28, 2022. 
 
You asked the Plan to pay for wound care. You say that you are requesting reconsideration for the services 
provided. 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 wound care provided on 
April 28, 2022.