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

We decided that the Plan does not have to pay forthe anesthesia services for Electroconvulsive Therapy provided on July 17, 2019.You asked the Plan to pay forthe anesthesia services. You say that the claim should be paid.The Plan denied your request. The Plan says the provider was contacted several times to obtain additional information, no information has been provided.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Medical records were not provided to verify medical necessity.Therefore, we decided that the Plan does not have to pay forthe anesthesia services for Electroconvulsive Therapy provided on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on March 9, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transluminal balloon angioplasty (37249) provided on April 
19, 2019. 
 
You asked the Plan to pay for transluminal balloon angioplasty. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service billed. 
 
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 37249 is transluminal balloon angioplasty (except 
dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation 
necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to 
code for primary procedure). 
 
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 transluminal balloon angioplasty. Our reviewer says that 
CPT code 37249 does not meet criteria for billing or reimbursement consideration. Our reviewer found 
multiple angioplasties performed in a single vessel, including treatment of separate and distinct lesions with a 
single vessel, are reported with a single code. If a lesion extends across the margins of one vessel into another, 
but can be treated with a single therapy, the intervention should be reported only once. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transluminal balloon angioplasty have not been met. Therefore, we decided that 
the Plan does not have to pay for transluminal balloon angioplasty (37249) provided on April 19, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 27, 2020, 
to February 25, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 27, 2020, to February 25, 
2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a physician's office urgent visit (99214) on March 4, 
2020. 
 
You asked the Plan to waive the copayment for a physician's office urgent visit. You say that this copayment 
should not have been charged to you. The Plan denied your request. The Plan says that the correct copayment 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
how much you should expect to pay for urgently needed services.  
 
We looked at your contract with the Plan. We did not see where the contract clearly says that enrollees must 
pay a $65 copayment for each visit for urgently needed services. The contract contains a range of copayments 
from $0 to $65 but does not clearly say how much enrollees must pay for urgently needed services. This means 
that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided 
that the Plan has to waive the copayment for a physician's office urgent visit (99214) on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on January 31, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1906) and a knee orthosis (L1833) 
provided to the enrollee on May 5, 2020. 
 
 
 
You asked the Plan to pay for the orthoses. You say that you have pain that may benefit from bracing. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show you do 
not have objective evidence of joint instability or sufficient evidence of any covered indications. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient?s medical 
record contains sufficient documentation of the patient?s medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Additionally, there is no objective indications of joint 
laxity or instability. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1906) 
and a knee orthosis (L1833) provided to the enrollee on May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 26, 2020. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says The Plan says this is an administrative determination for coding and is not based on clinical 
criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use of CPT 
81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 claim is missing the main code and identifier required by Medicare. Based on this information, 
we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services provided to the enrollee on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (99601 and 99602) provided on May 
29, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says procedure codes 99601 and 99602 have a 
value code of I which is not valid 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 CPT code. 
 
We find that CPT codes 99601 and 99602 are not supported in the record. Specifically, per the Physician Fee 
Schedule, CPT codes 99601 and 99602 have a status indicator of I. This means that these CPT codes are not 
valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 
home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home 
infusion therapy (99601 and 99602) provided on May 29, 2020.
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 there is no evidence of medical or nursing needs for an IRF. You need physical 
therapy (PT) and occupational therapy (OT) but not in an IRF. There is no evidence of medical issues that 
require monitoring by an inpatient rehab physician three times a week. The documentation does not support 
that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to 
rehab care. IRF admission is not medically necessary for you, and also does not meet the CMS coverage 
criteria due to lack of medical complexity. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from April 24, 2020, to 
April 27, 2020. 
 
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that the Plan should 
cover this bill. The Plan denied your request. The Plan says payment for self-administered drugs must be 
submitted to Medicare Part D. 
 
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 drugs provided 
from April 24, 2020, to April 27, 2020.  
 
Benefits for self-administered drugs under Medicare Part B 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office consultation (99244) provided on February 26, 
2020. 
 
You asked the Plan to pay for the office consultation. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 99244 has a status code of I which is 
not valid 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 CPT code. 
 
We find that CPT code 99244 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 99244 has a status indicator of I. This means that CPT code 99244 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the office consultation have not been 
met. Therefore, we decided that the Plan does not have to pay for the office consultation (99244) provided on 
February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on December 2, 2019 
under code G0483. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. You submitted additional 
information directly to Maximus for review regarding this appeal.  
 
The Plan denied your request. The Plan says the records provided are incomplete and do not show this testing 
was medically necessary or met the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Neither the medical records submitted to the Plan or the records submitted directly to this 
office show the enrollee met the criteria required for this testing. It should also be noted that Maximus cannot 
reprocess claims. New claim submission must be submitted to the Plan directly with supportive medical 
records. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on 
December 2, 2019 under code G0483.
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 requested LTACH specializes in 
recovery and their outcome scores demonstrate their level of success. You say that the LTACH provides acute 
care with active daily physician involvement, physician specialists, 24-hour nurse coverage, and therapies to 
optimize the level of recovery and to prevent any unwarranted send back. You say that the enrollee meets the 
admission criteria for an LTACH. The Plan denied your request. The Plan says the care being received at the 
current facility is appropriate. The Plan says that the guidelines for coverage of LTACH services have not been 
met. 
 
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 appears to be improving and requires additional short-term acute care 
services for weaning. However, the enrollee is likely to require more than 25 days worth of this care. The 
enrollee does not require services at the LTACH that are not already being provided in the current setting. 
There are no services at the LTACH which are not already available and covered at the current setting. 
Ongoing acute care services at the current hospital appear to be appropriate and transfer to a lower level of care 
may be considered when able. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the incision and drainage of an abscess (D7510) 
provided on June 5, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you would like to be reimbursed the 
$360 that you paid for this service. You say that you cannot afford this extra cost. You say that the tooth was 
infected and needed to be removed. You also say that this should be covered by insurance. The Plan denied 
your request. The Plan says incision and drainage of an abscess is not listed as 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 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. Additionally, the record shows that you were informed prior to 
receiving the service that it would not be covered and were provided a discount. Therefore, we decided that the 
Plan does not have to reimburse you for the incision and drainage of an abscess (D7510) provided on June 5, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more intensive therapy then what home 
health can offer. The Plan denied your request. The Plan says you do not require close medical supervision, or 
rehab needs that can only be met at 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 above. 
 
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 physician reviewer found 
that you have a left above the knee amputation, morbid obesity and sleep apnea. Your medical problems are 
stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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. The medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program. 
 
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.