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

 
We decided that the Plan does not have to pre-approve a L2-3 Coflex placement (22867, 69990). 
 
You asked the Plan to pre-approve a Coflex placement. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is experimental and therefore 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 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 a Coflex placement. Our reviewer says 
that the requested Coflex placement is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided medical records and review of the current peer-reviewed medical 
literature do not document that use of the Coflex device has been shown in controlled studies in a CMS-
approved journal to result in sustained long term health benefits in patients with low back with spinal stenosis. 
Therefore, the reviewer found that the requested Coflex placement is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Coflex placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a L2-3 Coflex placement (22867, 69990).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently receiving all necessary care at LTACH. Most likely will have 
tracheostomy capped. On percutaneous endoscopic gastrostomy (PEG) feeds. Most likely will be able to be 
discharged to skilled nursing facility (SNF) in a short period of time (less than 25 days). Lateral transfer to 
LTACH would not gain anything for the enrollee's care. LTACH is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diffusing capacity testing services described by code 
94729 performed on date of service April 27, 2023. 
 
You asked the Plan to pay for 94729. You say that 94729 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 94729 is denied because it was billed without the 
required modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that if the same physician or other supplier entity 
does not furnish both the TC and PC of the diagnostic service, the professional interpretation of a diagnostic 
test must be separately billed with modifier -26 by the interpreting physician.  
We looked at the file and Medicare rules. We confirmed that 94729 is a diagnostic service which has separate 
TC and PC. The claim was billed with place of service 21, indicating the enrollee received this diagnostic 
service in the inpatient setting, therefore, the same provider/supplier did not complete both the TC and PC for 
this service. According to Medicare rules, the provider performing the professional interpretation of the 
diagnostic service provided under arrangement to a hospital can bill and be paid for the PC of the service. The 
PC of a diagnostic service should be documented on the claim form with modifier -26. We have confirmed that 
94729 was billed without the required modifier -26. Based on this information, we decided that Medicare rules 
for coverage of 94729 have not been met. Therefore, we decided that the Plan does not have to pay for the 
diffusing capacity testing services described by code 94729 performed on date of service April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional routine transportation trips. 
 You asked the Plan to pre-approve the additional trips. You say that the additional trips are needed for primary 
care and specialists appointments. The Plan denied your request. The Plan says the record shows the enrollee 
has used all 12 one-way routine transportation trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for the enrollees primary care and specialists appointments. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve 6 additional routine transportation trips.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the PrismRA Molecular Signature test provided on September 1, 2023. 
 
You asked the Plan to pay for the PrismRA Molecular Signature test. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the DEX Diagnostic Registry considered the PrismRA 
test to be non-covered at the time 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. We find that the Plan has denied this service stating that the DEX Diagnostic 
Registry considered the PrismRA test to be non-covered at the time of service. However, no evidence of this 
test not being actively covered on the date of service in dispute in order to support that argument was provided. 
No other denial rationale was provided. Therefore, the Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the PrismRA Molecular Signature test provided on September 1, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on May 30, 2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you dont understand the 
additional $110 for an ultrasound/cardiology-echo-cardiology that was used during the procedure. 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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 the ultrasound provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921), local antimicrobial delivery 
(D4381), and other drugs and/or medicaments by report (D9630). 
 
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 
gingival irrigation (D4921), local antimicrobial delivery (D4381), and other drugs and/or medicaments by report (D9630).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the appropriate level of care for the 
enrollee is with the LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for the LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Therefore, the LTACH is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service May 23, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. The 
documentation supports that this panel used the nucleic acid probe technique. There is no evidence that 
multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code 
with one unit of service should be used. Based on this information, we decided that Medicare rules for 
coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for 
the panel testing billed for date of service May 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat lumbar radiofrequency ablation (RFA) (64635, 
64636). 
 
You asked the Plan to pre-approve repeat RFA. You say that the enrollee has severe pain. You say that the 
enrollee has been rescheduled multiple times. You also say that this is medically necessary. The Plan denied 
your request. The Plan says the records show it has been more than two years since the last RFA procedure. 
The Plan also says that there is not a clear cause of the enrollee's pain. 
 
The Plan follows Medicare rules. Medicare rules say that if there is an extended time, 2 years or more, since the 
last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be 
repeated. 
 
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 repeat RFA. Our reviewer says that the 
requested repeat RFA is not medically necessary. Our physician reviewer found the provided records show that 
it has been more than two years since the previous RFA procedure was performed. The reviewer also found 
that there is no recent imaging of her lumbar spine. Therefore, the reviewer found that the requested repeat 
RFA is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat lumbar radiofrequency ablation (RFA) (64635, 64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 13, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. 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 combined cardio and pharmacogenetics test panel was provided. We looked at the file and 
Medicare rules. This NGS panel was not billed with a single code as required. The records do not show that the 
panel was ordered due to the enrollees response to medication or due to a known gene-drug interaction. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the genetic testing provided on May 13, 2023, billed with codes 81225, 
81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81238.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing (0339U) provided to the enrollee on
December 2, 2022.

You asked the Plan to pay for the testing. 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. Maximus overturned the Plan's denial based on lack of information. The Plan requested a reopening
and stated that the claim was not submitted with the required information. The Plan is correct in this case. 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 the testing have not
been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (0339U)
provided to the enrollee on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 8, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code should be reprocessed. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 2, 2021, through 
June 30, 2021. 
 
You asked the Plan to pay for the home health services. You say that these services were rendered in good faith 
and should be paid. The Plan denied your request. The Plan says you billed an incorrect Type of Bill code and 
you did not bill a required Q code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).  
Based on this information, that means that final claims should be billed with Type of Bill code 0329 and 
replacement claims should be billed with code 0327.  In this case, you billed with Type of Bill code 0322, 
which is not correct. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from June 2, 2021, through June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with tilt and accessories, 
including electronic connection between wheelchair controller and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve the electronic connection. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is no medical need for the enrollee to control the 
power option with a joystick. 
 
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 electronic connection. Our reviewer 
says that the requested electronic connection is not medically necessary. Our physician reviewer found the 
provided records document that the enrollee has 4-/5 bilateral upper extremity hand and wrist strength and is 
independent with eating thus indicating the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. Therefore, the reviewer found that the 
requested electronic connection is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair with tilt and accessories, including electronic 
connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 27, 2022, to July 6, 
2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA is on file. You also said 
that you believe you are an in-network provider. 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 May 28, 2023. The NOA was not received by the Plan until November 10, 
2022. 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 June 27, 2022, to July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment 
supported crown (D6058) for tooth #19 provided on July 31, 2023. 
 
You asked the Plan to pay for D6057 and D6058. You say that you would like the Plan to pay 50% of this bill. 
The Plan denied your request. The Plan says the rendered dental implants are not covered 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 a custom 
fabricated abutment (D6057), and an abutment supported crown (D6058) for tooth #19 provided on July 31, 
2023.