Persius/hicric huggingface dataset:
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 documentation does not support necessity for admission to an IRF. The 
complexity of the enrollees medical, rehabilitation, and nursing needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollees 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
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 custodial care provided on September 29, 2022, to January 3, 
2023. 
 
You asked the Plan to pay for custodial care. You say that the enrollee did not have Greek medical insurance 
coverage and needed to pay for all of the medically necessary expenses out of pocket. The Plan denied your 
request. The Plan says the custodial care is not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care 
provided on September 29, 2022, to January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair accessory, power standing system 
(E2301). 
 
You asked the Plan to pre-approve the power standing system. You say that you are appealing so that the 
enrollee can get the equipment and devices needed to help make their daily life for the better. The Plan denied 
your request. The Plan says this item is not primarily medical in nature and is not covered. 
 
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 power standing system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the wheelchair accessory, power standing system (E2301).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transport brackets (K0108). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that the transport bracket is needed for you 
to attend doctors appointments, therapy appointments, fitting appointments for ankle-foot orthoses (AFO) and 
to have public access outside of your home. The Plan denied your request. The Plan says the transport brackets 
do not meet the Medicare criteria for durable medical equipment, as they will be used to transport the 
wheelchair, they will used outside the home, and do not have a medical purpose. 
 
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 pre-approve transport brackets (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes U0003 and U0005 rendered on March 23, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use for the services 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) U0003: 
 
Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-
cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r 
 
HCPCS U0005: 
 
Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-
cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high 
throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in 
addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does not 
support that there was use of high throughput technologies. In this case, there would be a more appropriate 
code to use. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes U0003 and U0005 rendered on March 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on April 24, 2023. 
 
You asked the Plan to pay for the chest x-ray. You say that you are appealing the denial with supporting 
documentation. 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 chest x-ray provided 
on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that you spoke with a Plan representative to 
determine what information was needed for the predetermination, and have submitted the records. The Plan 
denied your request. The Plan says according to your EOC, there is no coverage for core buildup (D2950). 
 
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, 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 core 
buildup (D2950).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiation therapy management (code 77427) provided on April 5, 2023. 
 
You asked the Plan to pay for 77427. You say that every other payor pays this code exactly the way it has been 
billed. The Plan denied your request. The Plan says that payment for this code should only be made after the 
fifth treatment has been delivered, not before. 
 
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. The Plan did not submit supporting medical records, nor did the Plan provide 
any documented attempts to obtain medical records. The Plan claims that this code was billed before 5 
treatment sessions were rendered. Without supporting records, we cannot determine whether the Plans denial 
reason is accurate or correct. Therefore, we decided that the Plan has to pay for radiation therapy management 
(code 77427) provided on April 5, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87502, 87798, 
87633, and 87634 provided on March 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services billed with codes 87502, 87798, 87633, and 87634. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are 
not supported. 
 
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. 
 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this case, 
we have confirmed that code 87502 is a column II code to column I code 87633. While code 87502 was billed 
with modifier -59, the medical records provided do not show that the service billed with the -59 modifier is a 
distinct procedural service. Code 87798 represents a not otherwise specified code; however, a complete 
description of the not otherwise specified code was not included. The order/lab requisition must include what 
laboratory test was ordered/requested in order to validate the code billed. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for codes 87633 and 87634. 
Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 87502, 
87798, 87633, and 87634 provided on March 13, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid, digital, binaural (V5259) provided on April 5, 
2023. 
 
You asked the Plan to pay for  hearing aid, digital, binaural (V5259). You say that you have submitted proof of 
rendered services and medical necessity. The Plan denied your request. The Plan says it has been determined 
that the billed services were not supported. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are medically 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 pay for  hearing aid, digital, binaural (V5259). Our 
reviewer says that does not meet the criteria for hearing aids. Our physician reviewer found while the services 
may be necessary and reasonable, the service provided cannot be verified because the submitted documents do 
not include the billed durable medical equipment (DME) order, as required by Medicare policy. 
 
 We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of  hearing aid, digital, binaural (V5259) have not been met. Therefore, we 
decided that the Plan does not have to pay for hearing aid, digital, binaural (V5259) provided on April 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on April 24, 2023. 
 
You asked the Plan to pay for an x-ray. You say that you are requesting reconsideration for the service 
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 an x-ray provided on 
April 24, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99308 and 99309 rendered from September 6, 2022, to 
September 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the information submitted does not support this level of service. 
 
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. The plan makes reference to having some medical records in their review and 
denial. However, no medical records were provided for review to MAXIMUS. Therefore, we decided that the 
Plan has to pay for procedure codes 99308 and 99309 rendered from September 6, 2022, to September 16, 
2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facet joint injection provided on November 03, 2022. 
 
You asked the Plan to pay for a facet joint injection. You say that this is supported in the records. 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 a facet joint injection 
provided on November 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on January 19, 2023. 
 
You asked the Plan to waive the copayment for lab services. You say that you do not think you should be 
responsible for the cost share. 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 $40 
copayment for lab services only when provided in an outpatient hospital facility. 
 
You have been asked to pay a $40 copayment for lab services. This item/service falls within the lab services 
only when provided in an outpatient hospital facility 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 
copayment for lab services provided on January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the yoga blocks purchased on March 10, 2023.  
You asked the Plan to pay for the yoga blocks. You say that the yoga blocks were required by the yoga class 
instructor, who requested they be purchased for the class. The Plan denied your request. The Plan says exercise 
equipment such as yoga blocks are not covered under your wellness allowance benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The contract 
states that your wellness allowance can be used toward your cost for a membership in a qualified health club or 
fitness facility. There is no supplemental benefit under your plan for exercise equipment. Therefore, we 
decided that the Plan does not have to pay for the yoga blocks purchased on March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (11732, 99345, 11721, 11730) provided 
on April 06, 2023. 
 
You asked the Plan to pay for home health services (11732, 99345, 11721, 11730). You say that you are 
appealing the claim payment denial. 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 
(11732, 99345, 11721, 11730) provided on April 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502 and 87798 billed for date of service 
February 27, 2023. 
 
You asked the Plan to pay for procedure codes 87502 and 87798. The Plan denied your request. The Plan says 
the claim 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 87502 
is a column II code to column I code 87633. 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. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, a complete description of the 
not otherwise specified code was not included. The order does not include which test was requested to validate 
this code. Based on this information, we decided that Medicare rules for coverage of procedure codes 87502 
and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87502 and 87798 billed for date of service February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that in January, you visited a dentist due to pain in 
your molars, and all they did was full mouth images x-rays. You also say that the provider they referred you to 
did not take your insurance, so you went to a provider in a different country since you were in pain. 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 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 requested item or service was exhausted on date of service January 16, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on April 6, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 17, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on May 17, 2023.