Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 01740 and 64415 provided on April 20, 2023. 
 
You asked the Plan to pay for procedure codes 01740 and 64415. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
supported. 
 
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. In this case, the Plan denied payment for services due to illegible medical 
records and lack of servicing provider name for verification. However, the Plan has provided no documentation 
showing they made any attempts to obtain these specific documents.  Therefore, we decided that the Plan has to 
pay for procedure codes 01740 and 64415 provided on April 20, 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: Favorable

 
We decided that the Plan has to pay for procedure code 86300 billed for date of service June 21, 2023. 
 
You asked the Plan to pay for the billed services. You say that the code was billed correctly. The Plan denied 
your request. The Plan says that duplicate lab tests are not reportable. 
 
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. 
 
We looked at the file and the rules. The file does not include sufficient evidence to support the Plans argument 
that the lab testing was a duplicate. The Plan has not made reasonable and diligent efforts to gather and forward 
to us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay 
for procedure code 86300 billed for date of service June 21, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a computerized knee (K1022, L5828, L5845, L5848, L5850, 
L5856). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show why a mechanical knee cannot meet the enrollee's 
functional needs. 
 
The Plan must follow Medicare rules. The rules say that coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records adequately demonstrate that the enrollee has K3 level functional potential and 
has specific needs for the requested components. Additionally, the plan attempts to create a more restrictive 
policy for defining K3 function that Medicare policy would allow. The requested items are part of a basic 
standard of care for all community above-knee amputee ambulators given that the evidence of their benefits 
and superiority to less sophisticated alternatives are well proven and long standing. Lesser devices would not 
meet the enrollee's needs, and amount to substandard 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve a computerized knee (K1022, L5828, L5845, L5848, L5850, L5856).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70486 billed for date of service May 15, 
2023.   
You asked the Plan to pay for procedure code 70486. You say that 2 units of 70486 should be paid as billed 
because they are supported in the medical record. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 70486 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 70486 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 70486 billed for date of service May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on July 20, 2023, billed with codes 
87481, 87653, 87798, and 87801. You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for the panel testing provided on July 20, 2023, billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on December 27, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on December 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from September 1, 2022, to November 3, 
2022. 
 
You asked the Plan to pay for SNF care. You say that the SNF services meet the Medicare coverage 
requirements. The Plan denied your request. The Plan says the SNF services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from September 1, 2022, to November 3, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services billed for date of service April 
11, 2023. 
 You asked the Plan to pay for the psychotherapy services. You say that this claim was denied incorrectly. The 
Plan denied your request. The Plan says there is no evidence that the provider complied with the primary care 
consultation requirement for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
billed for date of service April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee (BK), 
flexible protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no justification or context found in the record to suggest that this Beneficiarys prosthesis 
will be exposed to unusually harsh environments necessitating additional protection beyond what is provided 
with a typical cover (e.g., L5704, which has already been approved by the Plan, quite rightly along with the rest 
of the prosthesis). The records suggest the flexible cover is needed to protect the prosthesis from body fluids, 
but there is no documentation of what the exact source might be (e.g., there is no history of incontinence, need 
for dialysis, chronic draining wounds, etc.) to make this concern credible. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve addition, endoskeletal system, below knee (BK), flexible protective outer surface covering 
system (L5962).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for pontic (D6240) for teeth 7, 5, 3 and 10, retainer
crown (D6750) for teeth 2, 4, 6, 8, 9 and 11.

You asked the Plan to provide coverage for these dental services. The Plan denied your request. The Plan says
you do not meet the required coverage criteria. Maximus overturned the Plans denial. The Plan requested a
reopen and noted that the 2023 dental benefit states bridges will only be covered if no other teeth are missing in
the same arch or other than 3rd molars. The dental x-rays provided show you do not meet these criteria.

The Plan is correct in this case. 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.
Based on the dental records provided, you do not meet the criteria required for coverage of these services.
Therefore, we decided that the Plan does not have to provide coverage for pontic (D6240) for teeth 7, 5, 3 and
10, retainer crown (D6750) for teeth 2, 4, 6, 8, 9 and 11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on May 08, 2023, to May 11, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 Medicare Part B prescription drugs. 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. The total allowed amount for the prescription drugs is $3,892. You are 
being asked to pay $778.40 ($3,892 x 20% = $778.40). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on May 08, 2023, to May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87798, 87653, 87481, 87801) provided on July 
24, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the testing performed was 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 lab testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not sufficient explain the clinical benefit of this patient utilizing 
Polymerase Chain Reaction (PCR) testing instead of the standard of care urinalysis and culture to evaluate her 
dysuria. 
 
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 lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing (87798, 87653, 87481, 87801) provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CXBladder testing provided on April 17, 2023. 
 
You asked the Plan to pay for CXBladder testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue is for CxBladder. 
This is specifically not covered. Based on this information, we decided that Medicare rules for coverage of 
CXBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CXBladder 
testing provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 17, 2023, billed with 
codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 
81272, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you request a review of this decision, as 
you believe that the use of modifier 90 was necessary for the appropriate reimbursement of services rendered. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. The testing performed does not have FDA approval or clearance as a companion in vitro diagnostic 
or an FDA-approved or -cleared indication. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on April 17, 2023, billed with codes 81162, 81201, 81218, 81292, 81295, 
81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 81272, 81479.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99309 billed for date of service February 15, 2023. 
 
You asked the Plan to pay for code 99309. You say that you had to upload medical records in multiple files 
because they were too large. The Plan denied your request. The Plan says this code is not supported by the 
medical record. 
 
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 code 99309 have been met. In this 
case, although you have provided medical records, you have not provided any medical records that reflect the 
February 15, 2023, date of service.  There are no records with this date, so this code cannot be verified. 
Therefore, we decided that the Plan does not have to pay for code 99309 billed for date of service February 15, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 21, 2022, to 
October 20, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was timely filed. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 22, 2022. The NOA was not received by the Plan until June 21, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 21, 2022, to October 20, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care from 
October 22, 2023, forward. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
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. It appears that the Plans contracted delegate was provided the records for this 
skilled nursing facility (SNF) stay and has failed to forward them to support the decision to deny based on no 
medical necessity. Therefore, we decided that the Plan has to pre-approve the continuation of skilled nursing 
facility (SNF) care from October 22, 2023, forward.  
 
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.