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

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no arterial blood gas (ABG), done while stable, documenting chronic carbon dioxide (CO2) 
retention. If this enrollee does have chronic CO2 retention, may benefit from bilevel positive airway pressure 
(BiPAP) during sleep. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 12, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that the enrollee could not choose an in-network 
provider. The Plan denied your request. The Plan says this was not authorized. 
 
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 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on January 12, 
2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550, A4930, and J8499 billed for date of 
service July 13, 2022. 
 
You asked the Plan to pay for procedure codes A4550, A4930, and J8499. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Additionally, we find that procedure codes A4930 and J8499 
are not supported in the medical record. These codes have a Medically Unlikely Edit (MUE) of 0, which means 
it is inappropriate to bill these codes. Based on this information, we decided that Medicare rules for coverage of 
procedure codes A4550, A4930, and J8499 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes A4550, A4930, and J8499 billed for date of service July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for services billed to the enrollee for April 25, 2022, coded as 99203.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria for rural health clinics were not met. Maximus
overturned the Plans denial. The Plan requested a reopen and noted that the Plan is not stating the provider is a
"new" rural health clinic but that the provider did not submit the required rate letter for the date of service in
question. Medicare guidelines state the Plans are entitled to request this letter. The Plans must pay 80% of the
allowed charge, plus 20% of the actual charge minus the contractual copayment. Without a rate letter payment
cannot be properly calculated.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the Plan was unable to determine the appropriate payment without the submission of the rate letter. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for services billed to the enrollee for April 25, 2022, coded as 99203.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OralCDx brush biopsy provided on August 8, 2022. 
 
You asked the Plan to pay for the OralCDx brush biopsy. You say that this is a medically necessary test to 
check for cancer. The Plan denied your request. The Plan says this is not a medically necessary test. 
 
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 OralCDx brush biopsy. Our reviewer 
says that the OralCDx brush biopsy is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the clinical value and effectiveness of the WATS Oral Brush CDx Biopsy test in the setting of an unchanged chronic oral plague lesion has not been demonstrated and is not considered the 
standard of care. The review has determined that the items/services at issue in this case are not medically 
reasonable and 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 OralCDx brush biopsy have not been met. Therefore, we decided that the 
Plan does not have to pay for the OralCDx brush biopsy provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit billed to the enrollee under code 99203 (new patient) for on August 3, 2022, under Claim A.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and demonstrated that Claim A denied because the Plan paid for a new patient office visit within the past 3 years. The enrollee's claims history shows they received face-to-face services by another provider of the same specialty who belongs to the same group practice within the past three years. Review of the rendering provider taxonomy information indicates both providers practice under the same rendering provider taxonomy for Surgery. The Plan provided documentation to show to support this denial.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. In this case, this claim was incorrectly coded as a new patient visit by a provider or group that shows the enrollee was previously billed for this same service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for the office visit, billed to the enrollee under code 99203 for on August 3, 2022, under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided to you on 
January 24, 2023. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says this provider is not 
enrolled in 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 the durable medical equipment (DME) 
provided to you on January 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered insulin provided in the hospital from 
January 4, 2023, to January 6, 2023. 
 
You asked the Plan to pay for the self-administered insulin. You say that you explained to the nurse, after she 
checked your blood sugar, that your treatment plan from your endocrinologist for elevated blood sugar would 
be to take 1 unit of insulin for every 50mg over 100. You say that the nurse came back and handed you the 
syringe with the appropriate dose of insulin and you gave it to yourself.  The Plan denied your request. The 
Plan says the medication is not covered as a medical benefit under the Plan. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered insulin 
provided in the hospital from January 4, 2023, to January 6, 2023.  
 
Benefits for the self-administered insulin may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet certain criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the records show the enrollee has spinal 
stenosis also. A trial of fracture bracing is not documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertilfex device is experimental.More research is needed. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee does not have access to support from 
family to meet the requirements for home care. The Plan denied your request. The Plan says an IRF admission 
is 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 pre-approve 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 clinical documentation does not show that the enrollee requires daily skilled services 
on an inpatient basis in a skilled nursing facility; Thus, a SNF stay 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by a network provider. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
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 enrollee has been in bed for 22 days 
with no physical therapy and is not mobile. The enrollee believes if they go into a skilled nursing facility they 
will die. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current 
setting.  
 
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 where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara device (E1399).  
 
You asked the Plan to pre-approve a Volara device. You say that you are requesting reconsideration due to 
medical necessity and previous use of the Volara device was successful in treating the enrollee. The Plan 
denied your request. The Plan says Medicare guidelines state that there is no data to support that this device 
using IPV is effective and additionally, is not covered for use in the home. 
 
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 a Volara device have not been met. Specifically, Medicare guidelines state that the device is not 
covered for use in the home. Therefore, we decided that the Plan does not have to pre-approve a Volara device 
(E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88307, 88342-59 and 88341-59 billed for 
date of service July 11, 2022. 
 You asked the Plan to pay for procedure code(s) 88307, 88342-59 and 88341-59. You did not provide a 
specific argument for coverage with your appeal request. The Plan denied your request. The Plan says these 
codes are included in the facility payment and is not separately payable as billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88307, 88342-59 and 
88341-59. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88307, 
88342-59 and 88341-59. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88307, 88342-59 and 88341-59 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88307, 88342-59 and 88341-59 billed for date of service July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service October 26, 
2022. 
 You asked the Plan to pay for procedure code 99232. You say that the facility was responsible for getting 
authorization if one was required. The Plan denied your request. The Plan says payment for code 99232 is 
bundled into payment for code 93016. 
 
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 99232 
is a column II code to column I code 93016. 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.  Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 billed for date of service October 26, 
2022.  
 
Please note- we received your correspondence indicating that this patient has never been seen in your office.  
However, these services were rendered in an emergency room setting, not in an office setting.  Your office 
appealed these services with the Plan, so it is clear that the services in dispute were indeed provided by your 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  FoundationOne Liquid biopsy (0239U) provided January 1, 
2023. 
 
You asked the Plan to pay for  genetic testing. You say that you are requesting for FoundationOne Liquid CDx 
comprehensive genomic profiling test (F1LCDx) be reconsidered. The Plan denied your request. The Plan says 
the authorization the provider requested for this service was not approved, therefore this service 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. The records do not show that the enrollee has recurrent, refractory, 
metastatic or advanced cancer. The provider in this case is not a network provider with the Plan. The Plan did 
not pre-approve the item/service at issue. Per page 63 of the Plan's 2023 Evidence of Coverage says prior 
authorization requirements may apply for Outpatient diagnostic tests and therapeutic services and supplies. 
Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for  FoundationOne Liquid biopsy (0239U) provided 
January 1, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided from October 5, 2022, to December 14, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that you were provided prior authorization for 
continuity of care. The Plan denied your request. The Plan says that Medicare does not cover behavior health 
services performed by a social worker. 
 
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. psychotherapy provided from October 5, 2022, to December 14, 2022. 
Specifically, the Plan has not provided a Medicare rule that states that a Licensed Clinical Social Worker 
(LCSW) is not eligible to provided behavioral health services. The provider at issue in this case is a Licensed 
Clinical Social Worker (LCSW). Therefore, we decided that the Plan has to pay for psychotherapy provided 
from October 5, 2022, to December 14, 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.