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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services can be provided safely in an alternate 
setting.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 12, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 12, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pure Wick Female catheter. 
 
You asked the Plan to pay for the Pure Wick Female catheter. You say that the item should be covered. The 
Plan denied your request. The Plan says this item was purchased through a provider that is not certified with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Pure Wick Female catheter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116 and 97530 provided from February 
13, 2023, to February 27, 2023. 
 
You asked the Plan to pay for procedure codes 97116 and 97530. You say that the medical records support the 
codes as billed. The Plan denied your request. The Plan says the medical records do not support the codes as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 procedure codes 97116 and 97530. Our reviewer says that 
the medical records do not support the codes as billed. Our reviewer found the documentation does not support 
the GP modifier as the therapy was performed in assisted living. The medical record submitted for review does 
not include a plan of care to include, at minimum: (1) diagnoses; (2) long-term treatment goals; and (3) type, 
amount, and duration of therapy services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 97116 and 97530 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 97116 and 97530 provided from February 13, 2023, to 
February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 16, 
2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307. 
 
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 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on December 15, 2022.
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental service. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial because there was insufficient information. The Plan requested a reopening and provided documentation that these services have already been covered for the Plan year.
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 March 22, 2022. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ 
neoplasm, cell-free circulating DNA analysis of 55-74 genes (0242U) provided March 1, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the diagnosis from the Guardant test enabled the 
doctor to determine the optimal treatment pathway for their patient. The Plan denied your request. The Plan 
says there is insufficient documentation to corroborate the services an confirm Medicare coverage criteria has 
been met. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing have been met. 
additional records were needed to support the services in dispute. The records show that the Plan made multiple 
attempts to obtain additional records from the provider without success. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating 
DNA analysis of 55-74 genes (0242U) provided March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from August 25, 2022, to 
September 23, 2022, by an OON provider.  
 
You asked the Plan to increase the reimbursement for the acupuncture services. You say that you should have 
been reimbursed the full amount you paid minus the copayment for each visit. The Plan denied your request. 
The Plan says the services were 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 the acupuncture services provided from August 
25, 2022, to September 23, 2022, by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed all of the required drugs. There is a possible concern 
with regard to zoledronic acid and the bisphosphonates due to the enrollee's renal function and a possible 
concern for use of oral bisphosphonates due to gastroesophageal reflux disease (GERD). Records are 
inadequate (no estimated glomerular filtration rate (eGFR), however, to show that all of the plan's required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth #21. 
 
You asked the Plan to pre-approve the dental service. You say that there is no way to treat the enrollee without 
all the dental services being approved. 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 the Plan pre-approved the retainer crown (D6740) for tooth #19 on October 2, 2023; therefore, the 
enrollee's benefit for the requested item or service was exhausted on the date of approval of October 2, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth #21.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided April 29, 2023. 
 
You asked the Plan to pay for the emergency visit. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says another insurance is primary. 
The claim must be submitted to the primary insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
insurance as the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the 
emergency visit until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the emergency department visit provided April 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on January 24, 2023, billed 
with codes 87481, 87491, 87528, 87556, 87563, 87591, 87640, 87653, 87661 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on January 24, 2023, billed with codes 87481, 87491, 87528, 87556, 87563, 87591, 87640, 
87653, 87661 and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11046 billed for date of service April 21, 
2023. 
 You asked the Plan to pay for procedure code 11046. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says payment for code 11046 is bundled into payment for code 
14301. 
 
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 11046 
is a column II code to column I code 14301. 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 11046 billed for date of service April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CX Bladder Monitor test (0013M) provided April 24, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you disagree with this decision and request 
prompt review of this information and authorization of coverage for the CXbladder Monitor test. The Plan 
denied your request. The Plan says the CXbladder panel remains unproven at this time. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for CX Bladder Monitor test (0013M) provided April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on December 9, 2022, billed 
with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on December 9, 2022, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 
87640, 87651, 87798 and U0005.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy (PT) visits.  
 You asked the Plan to pre-approve the therapy services. You say that the additional PT is medically necessary 
for the enrollee's age-related physical debility, muscle weakness, and difficulty in walking. The Plan denied 
your request. The Plan says they will approve 4 additional visits out of the 8 being appealed to intensely focus 
on finalizing the home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has improved in terms of their mobility and can continue 
with a home exercise program. The enrollee may require some level of supervision for safety, but this does not 
require the services of a skilled physical therapist. Therefore, the 4 additional PT visits are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA). 
 You asked the Plan to pre-approve the TKA. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the records do not show that the enrollee has tried non-surgical conservative 
management for their knee pain. The Plan also says this is not medically necessary. 
 
Plan follows Medicare rules. Medicare rules say that a total knee arthroplasty (TKA) is considered reasonable 
and necessary for individuals when certain criteria are met. 
 
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 TKA. Our reviewer says that the 
requested TKA is not medically necessary. Our physician reviewer found detailed documentation regarding a 
trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. 
The documentation does not state that non-surgical medical management is not appropriate. Documentation 
does not evidence a failure of a previous osteotomy; or distal femur fracture; or malignancy of the distal femur, 
proximal tibia, knee joint or adjacent soft tissues; or failure of previous unicompartmental knee replacement; or 
avascular necrosis of the knee; or proximal tibia fracture. Therefore, the enrollee does not meet the coverage 
criteria for a total knee arthroplasty. 
 
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 TKA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total knee arthroplasty (TKA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 2, 2023, billed with 
codes 87481, 87653, 87798, 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that kindly review the attached documents and 
process this claim towards possible payment. 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. 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 
June 2, 2023, billed with codes 87481, 87653, 87798, 87801.