Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee from February 4, 2020, to February 26, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial stating insufficient information about the claim had been submitted. The Plan requested a reopen and provided additional information regarding the billing error. The Plan says thatthis claim denied because the provider billed with the inappropriate type of bill(TOB). The Plan states the provider billed this service with type of bill code (TOB) 0323 to show as Interim/Interim-Continuing Claims (Not valid for PPS Bills) , used when a bill for which utilization is chargeable for the same confinement or course of treatment had already been submitted, with additional claims coming. The Plan found the providerneeded to bill with TOB 0329 to show as Final Claim for an HH PPS EpisodeThePlan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim was submitted with an incorrect type ofbill code as it appears it was the final claim and there would be no further claim submitted for this enrollee. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee from February 4, 2020, to February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approvean Exogen Ultrasound bone healing system.You asked the Plan topre-approvean Exogen Ultrasound bone healing system. You say that an Exogen Ultrasound bone healing system is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for the Exogen ultrasound bone healing system. The Maximus Physician Reviewer determined that the requested bone growth stimulator was medically reasonable and necessary for the enrollee in this case. The reviewer cited factors evidencing a significantly increase risk of non-union with associated morbidity. The reviewer stated that there is support for the request for a bone growth stimulator as an indicated relative guideline exception.The health plan has requested a re-opening, citing an error on the face of the evidence. The plan has stated that it disagrees with our consultant's determination. The Plan argues that there is no medical necessity for expanding indications beyond the Medicare guidelines and that, based on the available medical literature, the device would not affect the outcome for long bones. Our Medical Director says that the medical records show you have a diagnoses of post-traumatic osteoarthritis of the right wrist, unspecified fracture of navicular [scaphoid] bone of right wrist, sequela, arthritis of carpometacarpal joint of the right thumb, right wrist scaphoid avascular necrosis, and right thumb basal joint osteoarthritis. You underwent a right wrist revision total arthrodesis on June 19, 2020. On July 28, 2020 the x-rays were looking good following revision wrist fusion. Based on the medical records, OurMedical Director has determined that the original review by the Maximus Physician Reviewer was incorrect. The documentation does not support that you had a nonunion fracture that had failed at least one surgical intervention for the treatment of the fracture. Medicare coverage criteria are not met We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Exogen Ultrasound bone healing system have not been met.Therefore, we decided that the Plan does not have to pre-approvean Exogen Ultrasound bone healing system.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for physician services provided on December 20, 2019.
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 Medicare billing criteria were not met. Maximus overturned the Plans decision. The
Plan requested a reopen and provided additional information regarding the claim. The Plan says that this claim
denied because two or more of the procedures submitted have been identified as services that are not
reasonably performed on the same date. The Plan says that they had previously paid for this service to the
same provider under another claim, which was submitted for review. The claim was also billed with modifier
26, which was also incorrect. The Plan instructs that the provider needed to bill with modifier 59.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case the claim
cannot be paid as billed based on the omission of an appropriate modifier to determine this was a separate and
distinct service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the
Plan does not have to pay for physician services provided to the enrollee on December 20, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 20,
2020.
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 provided additional information. The Plan states that this claim was denied
because the provider billed with an inappropriate modifier. The Plan states that the provider billed this
claim with modifier 59 but needed to bill with a modifier 79 to indicate unrelated procedure or service by the
same physician during a post-operative period. The Plan states the MLN Global Surgery Booklet explains that
during a Post-operative Period, two CPT modifiers are used to simplify billing for visits and other procedures
that are furnished during the post-operative period of a surgical procedure, but not included in the payment for
surgical procedure. The Plan states that that modifier 79 should be used when an unrelated subsequent surgery
is performed by the same surgeon within the global period of a major or minor surgery, regardless of whether
the subsequent surgery required a return to the operating room. Based on these guidelines, the Plan denied this
claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate CPT code and when necessary the
appropriate modifier. In this case, we have determined the claim submitted cannot be paid as billed due to the
omission of the appropriate modifier. Medicare rules for coverage of this service have not been met. Therefore,
we decided that the Plan does not have to pay for physician services provided to the enrollee on January 20,
2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forimaging services provided to the enrollee on December 27, 2019. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans decision stating it appeared two different providers rendered these services. The Plan requested a reopen and stated that this claim denied because the Plan hadalready made payment for this service under previous claim for the same service to the same enrollee. The Plan states the claims show both providers belong to the same physician group and both providers practice the same primary taxonomy. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day 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. Based on the medical records provided, this claim cannot be paid as billed due to the physician group relationship between the two providers. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay forimaging services provided to the enrollee on December 27, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forcomputed tomography (CT) scan services provided to the enrollee on December 31, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial stating the records show the services were provided. The Plan requested a reopen and stated the issue was not whether or not the service was provided but that it was billed incorrectly by the provider.The Plan says that the claim denied because they had already paid for this service under another claim. The case file includesthe medical records, but they do not support why this procedure had been rendered twice on the same day. The NPI website shows that both physicians' practice is Diagnostic Radiology Specialists. The case file includes the claim image for the appealed and referring claims that show that both providers belong to the same physician group. For payment consideration, the correct billing of this service needed to include modifier 59. In addition, instead of billing separately, the physicians should work togetherto select a level of service representative of the combined visits and submit the appropriate code for that level. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim in question cannot be paid as billed due to the omission of a code to show this was a separate and distinct service by physicians of the same group. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forcomputed tomography (CT) scan services provided to the enrollee on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on July 7, 2020. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight 
Psychotropic Assay rendered on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 6, 2020 by a non-
participating provider. 
 
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 the services were rendered by a non-participating provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided on July 6, 2020 by a 
non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 10, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee could not choose 
an in-network primary care physician, and your doctors are the only providers who will treat the enrollee's for 
primary care. You also say that there is currently no in-network doctor who can treat the patients at this facility. 
The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan 
also says that prior authorization was not obtained. 
 
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 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 subsequent nursing facility care provided on 
August 10, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pair of lead wires provided on September 29, 2020. 
 
You asked the Plan to pay for the TENS unit lead wires (A4557). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says a TENS unit has been purchased in the previous 12 months. 
 
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 TENS unit with leads was rented starting in May 2020 and 
bought on July 29, 2020. There is no documentation as to why the enrollee needs new leads before 12 months 
has passed. Based on this information, we decided that Medicare rules for coverage of the TENS unit lead 
wires (A4557) have not been met. Therefore, we decided that the Plan does not have to pay for the pair of lead 
wires provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IV moderate (conscious) sedation/analgesia- first 15 
minutes (D9239) and IV moderate (conscious) sedation/analgesia - each subsequent 15 minute increment 
(D9243). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit under the plan. 
 
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, the requested items or services are not 
among those covered under this benefit. The services are not listed in your handbook as a covered benefit; 
therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve IV 
moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and IV moderate (conscious) 
sedation/analgesia - each subsequent 15 minute increment (D9243).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve an MRI. You say that you would like approval for this MRI to be provided 
out-of-network. The Plan denied your request. The Plan says there are in-network providers available for these 
services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an MRI to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Maze procedure. 
 
You asked the Plan to pre-approve Maze procedure. You say that the results of this procedure far exceed either 
catheter-based therapy or medical therapy alone. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the clinical value and effectiveness of this procedure has not 
been demonstrated in peer-reviewed literature. 
 
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 Maze procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Maze procedure is a surgical approach in an attempt to restore and maintain normal sinus 
rhythm in patients with atrial fibrillation. Current guidelines do not recommend a surgical approach to ablation 
over conventional percutaneous ablation. At this time, the standalone surgical Maze procedure should be 
considered investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Maze procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Maze procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by an 
out of network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided on December 30, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart with 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the heart. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the patient is asymptomatic and 
active without chest pain or other cardiac symptoms.  As such, a coronary calcium scoring CT is considered a 
screening test which is not covered by CMS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the heart have not been met. Specifically, the service is not a 
covered benefit. Therefore, we decided that the Plan does not have to pre-approve a computed tomography 
(CT) of the heart with quantitative evaluation of coronary calcium (75571).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850 (J7320). 
 
You asked the Plan to pre-approve GenVisc 850. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the member has not tried and failed the required step therapy drugs. 
 
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 GenVisc 850. Our reviewer says that 
the enrollee has not met step therapy requirements for the service requested. Our physician reviewer found the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation 
does not outline contraindications or reasons these medications were not considered or that 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 GenVisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GenVisc 850 (J7320).