Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) provided on August 21, 2023. 
 
You asked the Plan to pay for the vaccine. You say that your doctor told you to get this shot. You also say that 
you received a bill. The Plan denied your request. The Plan says the Tdap vaccine is not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) provided on August 21, 2023.
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 the services are medically necessary for you to 
receive close medical management and therapy services before returning home. The Plan denied your request. 
The Plan says you do not meet the criteria for admission to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint (V2744) and anti-reflective coating 
(V2750) provided on July 8, 2023. 
 
You asked the Plan to pay for the photochromatic tint and anti-reflective coating. You say that the use of these 
coatings are not merely cosmetic, but are medically necessary. The Plan denied your request. The Plan says 
you were advised of what was covered by your vision insurance before you ordered your glasses. The Plan also 
says that regardless of possible medical necessity, the enhancements are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyeglass frames and eyeglass lenses (including single, lined bifocal, lined trifocal, 
progressive, and lenticular lenses) or contact lenses. 
 We looked at the file and the Plan's rules. Specifically, lens enhancements are not covered under your plan. The 
record also shows that the Plan contacted the provider and was advised the provider informed you about your 
eyewear coverage prior to ordering the glasses. Based on this information, we decided that the Plan's rules for 
coverage of the photochromatic tint and anti-reflective coating have not been met. Therefore, we decided that 
the Plan does not have to pay for the photochromatic tint (V2744) and anti-reflective coating (V2750) provided 
on July 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for problem-focused evaluation, periapical x-rays, and a core 
buildup. 
 
You asked the Plan to pay for 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 pay for problem-focused evaluation, periapical x-rays, and a core buildup.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 22902-59 billed for date of service June 6, 2023. 
 
You asked the Plan to pay for code 22902-59. You say that medical records have been provided to support 
payment. The Plan denied your request. The Plan says code 22902-59 is not supported by the medical record. 
The operative report did not include documentation of an excision of a tumor from the soft tissue of the 
abdominal wall in the subcutaneous tissue for less than 3 cm; therefore, the billed service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 22902 is Excision, tumor, soft tissue of abdominal wall, 
subcutaneous; less than 3 cm. 
 
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 code 22902-59. Our reviewer says that code 22902-59 is not supported by the medical record. Our reviewer found there is no description of this procedure in the record. 
There is no mention of the removal of a tumor from the subcutaneous tissue of the abdomen wall. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 22902-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 22902-59 billed for date of service June 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0482 and 80307 billed for May 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes G0482 and 80307 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is definitive drug testing, 15-21 drug classes. The 
definition of code 80307 is drug test(s), presumptive, any number of drug classes, any number of devices or 
procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, 
KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without 
chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) 
includes sample validation when performed, per date of service.  

We find that CPT codes G0482 and 80307 are not supported in the medical record. Specifically, there are no 
laboratory results for the billed date of service supporting that the services were performed. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes G0482 and 80307 billed for May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 for date of service June 5, 2023. 
 
You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim should be submitted to the primary insurer. 
 
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 directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for procedure code 99214 until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for procedure code 99214 for date of service June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
11, 2023.  
 
You asked the Plan to pay for procedure code 86077. You say that the services are supported by the records. 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on August 28, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you cannot afford to pay this cost up front. 
You say that you were not aware you would need to do this. The Plan denied your request. The Plan says the 
vaccine services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and 
administration (90471) provided on August 28, 2023.  
 
Benefits for the vaccine services 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: 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 the enrollee currently meets full IRF criteria. 
Waiting for a standard service decision may seriously jeopardize their life, health, or ability to regain maximum 
function. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are 
requesting do not meet the requirements for approval.  
 
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 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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 procedure codes 80307 and G0483 billed for date of service 
May 3, 2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 80307 is presumptive drug testing. The definition of code 
G0483 is definitive drug testing of 22 or more drug classes. We find that CPT codes 80307 and G0483 are not 
supported in the medical record. The records provided do not include presumptive testing results. The records 
do not show that at least 22 drug classes were tested. Based on this information, we decided that Medicare rules 
for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 80307 and G0483 billed for date of service May 3, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Briumvi. 
  You asked the Plan to pre-approve Briumvi. The Plan denied your request. The Plan says the enrollee has not 
tried or cannot use Ocrevus. 
 
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 Briumvi. Our reviewer says that the 
enrollee has not tried and failed the required drug. Our physician reviewer found there is no indication that the 
Plan's required drug would likely be less effective 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 Briumvi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Briumvi.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on September 7, 2023. 
 
 
 You asked the Plan to pay for the COVID-19 test. You say that the test was medically necessary and not 
available through the vendor in a timely manner. The Plan denied your request. The Plan says the service is not 
a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare and the Plan do not pay for OTC items and 
the COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-
19 test provided on September 7, 2023.
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 inpatient services are needed due to your size and not 
being able to walk. The Plan denied your request. The Plan says the services you need can be provided safely 
in other settings, for example, a skilled nursing facility (SNF), at home with home health services, or at home 
with outpatient therapy.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99233 performed on June 18, 2023.  
 
You asked the Plan to pay for 99233. You say that 99233 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99233 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
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 99233. Our reviewer says that 99233 is not 
supported in the documentation. Our reviewer found this case pertains to an enrollee with chronic obstructive 
pulmonary disease and asthma who was admitted for pneumonia. For date of service June 18, 2023, the history 
and exam are appropriate. The documentation does not support a high level of medical decision-making, nor is 
there documentation of 50 minutes or more spent providing this service. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99233 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99233 performed on June 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide separate coverage for a PTB brim (L5632), flexible inner
socket (L5645), acrylic lamination (L5629), ultralight material (L5940), distal cushion (L5668, alignable
system (L5910), and closures (L2330).

You asked the Plan to provide separate coverage for these prosthetic component codes. The Plan denied your
request. The Plan says these items cannot be unbundled and requested separately. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria. The Plan noted that codes L5632, L5645, L5629, L5940 and L5668 were requested in error as these
are bundled codes and cannot be paid separately from L5020.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say providers must
request equipment appropriately. The Plan approved the requested partial foot (L5020). The Medicare rules
show the remaining codes were unbundled and requested separately in error. Therefore, we decided that the
Plan does not have to provide separate coverage for a PTB brim (L5632), flexible inner socket (L5645), acrylic
lamination (L5629), ultralight material (L5940), distal cushion (L5668, alignable system (L5910), and closures
(L2330).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing billed with code 0012M for date of 
service August 3, 2023. 
 
You asked the Plan to pay for the CxBladder testing billed with code 0012M. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for CxBladder (code 0012M) is not 
covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of the CxBladder testing 
billed with code 0012M have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder testing billed with code 0012M for date of service August 3, 2023.