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

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service October 
26, 2022. 
 
You asked the Plan to pay for procedure code 81345-GZ. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says payment for code 81345-GZ is bundled 
into payment for code 0089U. Additionally, procedure code 81345 was billed with the GZ modifier, which by 
definition means that this service does not meet the criteria for Medicare coverage. 
 
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 
81345-GZ is a column II code to column I code 0089U. This claim has not been billed with an appropriate 
modifier to bypass the edit. Additionally, procedure code 81345 was billed with the GZ modifier, which means 
that this service does not meet the criteria for Medicare coverage. 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 
81345-GZ billed for date of service October 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuropsychological testing (96116, 96132, 96133, 96136, 
96137) provided on August 9, 2023.  
 
You asked the Plan to pay for the neuropsychological testing. You say that this service was medically 
necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support the 
billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the neuropsychological testing have 
been met. No testing results or procedure reports were provided. The records show the plan requested 
additional information and none was provided. Therefore, we decided that the Plan does not have to pay for 
neuropsychological testing (96116, 96132, 96133, 96136, 96137) provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the DaVinci Device provided on August 9, 2023. 
 
You asked the Plan to pay for the DaVinci Device. You say that you were told that you would be reimbursed 
80% for the device. The Plan denied your request. The Plan says that the device does not meet the requirements 
for durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that your call information with the Plan was not submitted. This means 
that we cannot confirm if you were told you needed to submit an authorization request. Therefore, we decided 
that the Plan has to pay for the DaVinci Device provided on August 9, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep anesthesia (D9222, D9223), therapeutic parenteral 
drugs (D9612), alveoloplasty in conjunction with extractions (D7310), primary closure of a sinus perforation 
(D7261), and reduction of osseous tuberosity (D7485). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 pre-approve deep 
anesthesia (D9222, D9223), therapeutic parenteral drugs (D9612), alveoloplasty in conjunction with extractions (D7310), primary closure of a sinus perforation (D7261), and reduction of osseous tuberosity 
(D7485).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF)
services you are requesting do not meet the requirements for approval. Maximus overturned the Plan's denial.
The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The records
clearly show that at the time of the appeal prior to admission the enrollee did not meet all the criteria required
by Medicare for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
June 29, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
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 at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798) provided on February 14, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the information provided does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the lab services have been met. No 
clinical records were provided to show this service was medically necessary. Only lab orders were submitted. 
The plan requested additional records and none were provided. Therefore, we decided that the Plan does not 
have to pay for lab services (87798) provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided June 
13, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you have attached the 
supporting documentation, please reprocess the claim. The Plan denied your request. The Plan says under 
Medicare, the request 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 looked at the file and Medicare rules. The record does not show a diagnosis of psoriasis. There is also no 
indication of intractable psoriasis, as there is no indication the enrollee has failed other treatments for psoriasis. 
There are also no other factors described that would justify treatment at home rather than alternative sites, like 
a clinic or the hospital. Based on this information, we decided that Medicare rules for coverage of the 
ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultraviolet light therapy system (E0691) provided June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided on May 11, 2023. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing is not FDA approved and the 
enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS tests are covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) provided 
on May 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
March 16, 2022, to March 21, 2022, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this
should be paid for. The Plan denied your request. The Plan says that the Payment Integrity post-service postpay
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect
DRG.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with secondary
diagnosis code, N17.9, defined as Acute kidney failure, unspecified. Our Medical Director states that the
enrollee had a medical history that included hypertension and diabetes. The enrollee previously underwent
open reduction and internal fixation of a bimalleolar fracture of the right ankle. The enrollee presented to the
hospital on March 16, 2022, with fever, and redness and swelling of the right ankle. Vital signs were
unremarkable. Laboratory studies were notable for an elevated white blood count (15.9), and modest elevations
of the blood urea nitrogen (BUN) (27) and creatinine (1.3). Carbon dioxide was low (20). The BUN/creatinine
ratio was 20.8 (elevated). The enrollee was diagnosed with an infected surgical wound, with likely infected
hardware. Acute kidney injury was treated with the initiation of normal saline. Intravenous (IV) antibiotics
were administered. On March 17, 2022, the BUN was 29, the creatinine was 1.1, and the carbon dioxide was
17. On March 18, 2022, it is documented, "Most likely dehydrated/prerenal continue with IV fluid monitoring
kidney function." The BUN was 26, the creatinine was 1.0, and the carbon dioxide was 19. While the enrollee
had an apparent increase in her serum creatinine, the documentation does not support that the enrollee's volume
status had been optimized, as the laboratory creatinine value returned to a normal range with hydration. Our
Medical Director found that the enrollee's condition did not meet Medicare criteria for the inpatient hospital
services provided from March 16, 2022, to March 21, 2022, at the DRG originally billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from March 16, 2022, to March 21, 2022, at the
Diagnosis Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on August 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will cover approved tests covered for 
dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The Guardant Reveal test (using unique identifier Z00D5) is not a 
covered service per the Palmetto GBA DEX Registry. 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 (81479) provided on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
internal medicine physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied 
your request. The Plan says this is considered experimental and investigational due to insufficient evidence of 
safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services described by code 98940 billed for 
date of service June 12, 2023. 
 
You asked the Plan to pay for 98940. You say that 98940 should be paid as billed because it was medically 
necessary and is supported in the documentation. The Plan denied your request. The Plan says 98940 is denied 
because it was not billed with a diagnosis code that supports medical necessity.  
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis code M54.2 is not listed as a diagnosis 
code that supports medical necessity for procedure code 98940. 
 
We looked at the file and Medicare rules. In this case, we confirmed that procedure code 98940 was billed with 
only diagnosis code M54.2, defined as cervicalgia, assigned. There are no additional diagnoses listed on the 
claim. Per LCA A58345, M54.2 is not a diagnosis code that supports medical necessity when billing 98940. As 
such, the denial of 98940 is appropriate. Based on this information, we decided that Medicare rules for coverage of 98940 have not been met. Therefore, we decided that the Plan does not have to pay for the 
chiropractic services described by code 98940 billed for date of service June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 23, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits and 5 home health 
physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented home health skilled nursing needs. No nurse records have been identified for review. You do 
not have documented home health physical therapy needs. You appear to be at a new, lower level of 
function. As such, the requested home health skilled nursing and home health physical therapy 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 home health skilled nursing visits and 5 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that your current shower chair is falling apart and 
no longer effective or safe. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gym membership with a non-participating provider. 
 
You asked the Plan to pre-approve gym membership with a non-participating provider. You say that this 
facility is a great fit for you. You also say that this facility will work out for you with your daughter as well. 
The Plan denied your request. The Plan says you asked for coverage of gym membership to a facility as they 
have a program that fits your needs. The Plan also says that facility is not a participating Silver Sneaker 
provider. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when they are a Silver Sneakers participating facility. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the requested facility is not a 
participating facility with Silver Sneakers. Therefore, we decided that the Plan does not have to pre-approve 
gym membership with a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incomplete endodontic therapy (D3332), apicoectomy 
(D3421), and retrograde filling - per root (D3430). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 pre-approve 
incomplete endodontic therapy (D3332), apicoectomy (D3421), and retrograde filling - per root (D3430).