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

 
We decided that the Plan does not have to pay for physician's services for an encounter for examination for a 
driving license provided on October 28, 2022. 
 
You asked the Plan to pay for physician's services for an encounter for examination for a driving license. You 
say that you did not know that a routine exam would be excluded from coverage just because of its reason. The 
Plan denied your request. The Plan says after review of the medical records it was determined the diagnosis is 
accurate and the claim processed correctly. These services are non-covered per enrollees Evidence of 
Coverage. 
 
The Plan contract does not cover physical exams for driving licenses. 
 
We looked at the file and the Plans rules. The Plan says that physical exams for driving licenses are not 
covered under any condition. Therefore, we decided that the Plan does not have to pay for physician's services 
for an encounter for examination for a driving license provided on October 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99291) provided on June 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment is 
included in the global surgery payment for code 12013. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that payment for code 99291 is included in the global surgery 
payment for code 12013 provided on the same day. However, the Plan has not provided documentation 
showing that code 12013 was billed and paid on the same date of service. Without supporting documentation, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services 
(99291) provided on June 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service September 
11, 2022. 
 
You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. No TC 
billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT code 85060 
furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare 
rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 85060 billed for date of service September 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service July 31, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service July 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 27, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the requested 
records were not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the treating physicians intent that the testing be performed. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible the laboratory services provided on May 17, 
2022, by an out-of-network provider. 
 
You asked the Plan to waive the deductible the laboratory services. You say that you are appealing your cost-
share responsibility for the services you received. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Review 
of the file shows that you received the laboratory services on May 17, 2022. At the time of services rendered 
you had not met your $750 deductible; therefore, you have been asked to pay $385.94 for the services to apply 
to your deductible. Furthermore, the Plan states that you are not being charged for CPT code 87086. This cost 
sharing is a contractual obligation that had not been met at the time the laboratory services was received on 
May 17, 2022. Therefore, we decided that the Plan does not have to waive the deductible the laboratory 
services provided on May 17, 2022, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 7, 2022 to 
August 11, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 7, 2022 to 
August 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271), carboplatin (J9045), paclitaxel (J9267), Famotidine (J3490), diphenhydramine HCL (J1200) and dexamethasone sodium phosphate (J1100).

You asked the Plan to pre-approve the medication. You say that the medication regimen is medically necessary for the enrollee's treatment for gastroesophageal cancer. The Plan denied your request. The Plan says the use of this drug/regimen is not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 medication. Our physician reviewer found the requested use of the drug regimen is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal.

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (CPT code J9271), carboplatin (J9045), paclitaxel (J9267), Famotidine (J3490), diphenhydramine HCL (J1200) and dexamethasone sodium phosphate (J1100).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726, 75774 and 76380 billed for date of 
service June 7, 2022. 
 
You asked the Plan to pay for procedure codes 75726, 75774 and 76380. You say that the enrollee had multiple 
exams on the date in question. The Plan denied your request. The Plan says the payment for these codes is 
included in the payment for code 37243. Although codes 75774 and 75726 were billed with a modifier for 
separate payment, the documentation does not support that this modifier was used correctly 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. 
 
In this case, we have confirmed that codes 75726, 75774 and 76380 are all column II codes to column I code 
37243. Code 76380 has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met for code 76380. However, codes 75726 and 75774 and 
were billed with a modifier.  
 
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 75726 and 75774. Our reviewer says that 
the use of the 59 modifier is not supported for these services. Our reviewer found that in this case, a primary 
intervention procedure was performed, which includes all radiological supervision and interpretation, and 
therefore these procedures cannot be verified as separate procedures. 
 
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 75726, 75774 and 76380 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 75726, 75774 and 76380 billed for date of 
service June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided 
on September 26, 2022. 
 
You asked the Plan to pay for the CGM. You say that the enrollee needs the CGM and sensors every 30 days in 
order to check their blood glucose level. The Plan denied your request. The Plan says the date of service billed 
on this claim does not match the shipping date or date of delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service provided does not match the 
shipping date or the delivery date.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for a 
therapeutic continuous glucose monitor (CGM) provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds services coded 12001 
provided on September 5, 2022. 
 
You asked the Plan to pay for the simple repair of superficial wounds services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not included in other 
services 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 12001 is simple repair of superficial wounds of scalp, 
neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. 
 
 We find that CPT code 12001 is not supported in the medical record. Specifically, this service was provided 
within 10 days of procedure 10061 (incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, 
cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple). This means 
payment for this service is included in the global surgery package of code 10061 and is not separately payable 
as billed. Based on this information, we decided that Medicare rules for coverage of the simple repair of 
superficial wounds services have not been met. Therefore, we decided that the Plan does not have to pay for the 
simple repair of superficial wounds services coded 12001 provided on September 5, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (81442, 81413, 81410, 81408, 81407, 81404, 81411) provided to the enrollee on August 16, 2021.
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan denied your request. The Plan says that these services were not billed with the appropriate codes for a cardiovascular disease screening. Maximus overturned the Plan's denial stating that there was insufficient information provided. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly state that Cardiovascular disease screening is to be billed with certain HCPCS codes. The lab services for Cardiovascular disease screening were not billed with the correct codes.
Therefore, we decided that the Plan does not have to pay for the lab services (81442, 81413, 81410, 81408, 81407, 81404, 81411) provided to the enrollee on August 16, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. 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 Durolane. 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 the required drugs. There is no indication 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
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 updated clinical information provided supports 
the need for IRF care. The Plan denied your request. The Plan says the enrollee does not meet he Medicare 
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 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 syncope, fall, C1 fracture, alcohol withdrawal, and pneumonia. The enrollee's medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that an IRF stay will improve the enrollee's overall function and safety at an ambulatory level. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria for admission to an IRF. Maximus overturned the Plans denial stating IRF care would be necessary. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan is correct in this case. 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.
The rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The medical records indicate the enrollee would not be expected to be able to actively participate in and to benefit from an intensive rehabilitation therapy program. Also, social reasons for care needs in the home do not meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LUCI model 101 system.
You asked the Plan to pre-approve the LUCI model 101 system. You say that this is medically necessary. The Plan denied your request. The Plan says this item does not serve a medical purpose and cannot be covered. Maximus overturned the Plan's denial stating that this is medically necessary. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that that additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. We looked at the file and Medicare rules. This item is used as a power wheelchair add-on used for convenience and is most effective for use outside the home.
Based on this information, we decided that Medicare rules for coverage of the LUCI model 101 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the LUCI model 101 system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. This procedure improves the quality of life of patients suffering from 
vertebrogenic low back pain. The Plan denied your request. The Plan says unproven and not medically 
necessary procedures are not covered by Medicare. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and investigational. There is more research 
needed due to insufficient evidence of efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 additional home health skilled nursing visits.