Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) for teeth #'s 9 and 11, as 
well as the pontic teeth (D6241) requested for teeth #'s 6-11. 
 
You asked the Plan to pre-approve the implants and pontic teeth. You say that it is felt that this should be 
covered. The Plan denied your request. The Plan says coverage was approved for two of the requested dental 
implants. However, the request for the D6241 pontics for teeth 6, 8, 9, and 11 is not possible as these items 
cannot be placed over the planned implants. The pontics requested for teeth 7 and 10 are not covered as this 
would be an implant-supported pontic which is noncovered.  
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, only two implants can be covered per 
year, which were approved by the Plan. The other two implants exceed the maximum benefit. In addition, the 
pontics requested would be supported by the implants requested, and implant-supported supported fixed 
bridges are not covered. Therefore, we decided that the Plan does not have to pre-approve endosteal implants 
(D6010) for teeth #'s 9 and 11, as well as the pontic teeth (D6241) requested for teeth #'s 6-11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided superficial radiation therapy (IGRT).

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says based on the additional information available, the request does not meet the Medicare or health plan coverage criteria.

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 the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the treatment itself is not disputed in this case but rather the need for image guidance. Usually IGRT is used when critical structures are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply to this patient for which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Therefore to bill for daily simple simulations and/or IGRT for a technology for which need has not been established by published data or supported by consensus guidelines (many of which recommend against
treatment with these devices in general) is not necessary. Billing for daily IGRT which would not be "furnished in accordance with accepted standards of medical practice."
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor supplies provided to the
enrollee on December 9, 2021.
You asked the Plan to pay for this claim. You say that these supplies should be paid by the Plan. The Plan
denied your request. The Plan says insufficient medical records were provided to show all of the required
coverage criteria were not met. Maximus overturned the Plans denial. 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 has specific coverage criteria
for this equipment and supplies, and all those criteria listed must be met for coverage. The medical records
provided do not show the enrollee meets all the criteria listed in the Medicare rules section of this letter.
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor supplies provided to
the enrollee on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for skin substitute and injection services provided to
the enrollee on November 17, 2021, and November 18, 2021.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan
demonstrated that the provider is saying that the billed code C1762 is intended to be the associated "qualifying
procedure" (i.e., skin substitute product). The Plan notes under the "Data HCPCS file", the value shown under
"skin substitute HI" is "0" which states that this code is not an appropriate high-cost skin substitute application
product. The Plan notes that per the Medicare guidelines, the Plan denied the code 15271 as per the OCE edit
87 and denied all other codes on the claim due to the Return to Provider (RTP) disposition associated with
OCE Edit 87.
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, this claim
could not be paid as billed due to errors with the codes billed involving, they type of skin substitute product
described.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have
to pay for You asked the Plan to pay for skin substitute and injection services provided to
the enrollee on November 17, 2021, and November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mammography services billed to the enrollee for November
30, 2021 and billed separately under codes 77065 and 77052.
You asked the Plan to pay for these services separately. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus
overturned the Plans denial stating the services billed were found to be medically necessary. The Plan
requested a reopen and stated issue was not medical necessity but that codes 77065 and 77052 cannot be
separately billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Both codes were billed to the enrollee for the same visit. Code 77052 cannot be billed
separately due to its bundled relationship with 77065. Medicare rules for coverage of these services being
billed separately have not been met. Therefore, we decided that the Plan does not have to pay for
mammography services billed to the enrollee for November 30, 2021 and billed separately under codes 77065
and 77052.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 9, 2022.
You asked the Plan to pay for these services. 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 for
insufficient information in the case file regarding the denial. The Plan requested a reopen and provided
additional information. The Plan notes the claim was billed without the unique test identifier code required by
Medicare and therefore could not be paid as billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case the claim was submitted without the unique test identifier or approved
DEX Z-Code code required by Medicare. Medicare rules for coverage of these services have been met.
Therefore, we decided that the Plan does not have to pay for genetic testing provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for drug testing (80307) provided to the enrollee on April 6, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial for insufficient information in the case file regarding the denial of the claim. The Plan requested a
reopen and provided additional information.
The Plan demonstrated the claim system shows that this claim was billed with code 80305, which is a
presumptive drug testing code. Per the Medicare guideline, only one code from code range 80305 to 80307
may be reported per date of service. The Plan correctly denied code 80307 as it is also a presumptive drug
testing code within the code range of 80305 to 80307.
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 code.
In this case, this claim could not be paid as billed due to both codes being within the same presumptive drug
code range only allowing one code in this range to be billed per day of service. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
(80307) provided to the enrollee on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fender covers for a power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve fender covers for a power wheelchair (PWC).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) provided on September 16, 2022.

You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you were told your copayment would be $45 for the specialist visit. You did not know there was a copayments for the MRI. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $150 copayment for magnetic resonance imaging (MRI). This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) provided on September 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99221) provided on September 19, 2022.

You asked the Plan to pay for hospital care. You say that this service was medically necessary. The Plan denied your request. The Plan says no supporting documentation was received for this claim. In addition, this service would need a modifier to indicate that it was not related to or included in the global surgery payment for another service provided to this enrollee.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of hospital care have been met. Specifically, no medical records were provided to support that this service was medically necessary and was reported correctly. Therefore, we decided that the Plan does not have to pay for initial hospital care (99221) provided on September 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgery services billed to the enrollee on September 22, 2021.
You asked the Plan to pay this claim as billed. 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 stated that Maximus did not apply the correct billing criteria. The Plan
demonstrated that the claim history shows that surgical procedure code 49440 for September 22, 2021, was
performed by Provider A and surgical procedure code 36558 for September 17, 2021, was performed by
Provider B. Procedure code 49440 was not billed with the required a 79 modifier. A review of Box 11 on both
claims shows both providers are part of the same medical group and bill with the same primary specialty or
Radiology, Vascular and Interventional Radiology, and subspecialty as: Internal Medicine. Both claims also
show the same Taxonomy code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided to the same patient by the same physician or more than one physician in the same specialty
in the same group, only one service may be reported unless the services are for unrelated problems. Based on
the documentation provided, this claim cannot be paid as billed due to the physician group relationship between
the two providers and the omission of the modifier required to identify this as a separate and distinct service.
Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for surgery
services billed to the enrollee on September 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation services.

You asked the Plan to pre-approve ambulance transportation services. You say that the clinical information provided supports the need for ambulance transportation services. The Plan denied your request. The Plan says the records show the enrollee is able to ambulate short distances, sit in a chair and is not bed-bound. The Plan says that the enrollee does not have any acute conditions which require continuous monitoring.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 ambulance transportation services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are contraindicated for this enrollee. The enrollee is being discharged from acute care and transferred to skilled nursing facility. Documentation indicates that he can transfer sit to stand and stand to sit with minimal assistance. The documentation does not support that the enrollee needs the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The enrollee is hemodynamically stable and there is no documentation of any need for basic life support or advanced life support monitoring. The documentation does not support that the ambulance transport is medically reasonable and necessary 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 ambulance transportation services have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete
mandibular denture (D5120) provided on December 10, 2021.
You asked the Plan to pay for these services. You say that these dentures should be covered by the Plan. The
Plan denied your request. The Plan says the contract says that coverage is not provided for the initial
installation of a bridge or denture to replace teeth missing prior to coverage. Maximus overturned the Plans
denial for a lack of dental records in the file. The Plan requested a reopen and provided the required records.
The Plan is correct in this case. 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 Plan contract says that coverage is
not provided for the initial installation of a bridge or denture to replace teeth missing prior to coverage. The
dental records show you were missing teeth prior to the request for dentures.
Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and
complete mandibular denture (D5120) provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36598 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 36598. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says procedure code 36598 has a 
status indicator of T and was billed with another service (36593) on the same date. Therefore, this service is 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 36598 has a status indicator of T on the Physician Fee Schedule and was billed 
with a payable service on the same date by the same provider. This means that procedure code 36598 is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 
36598 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 36598 
billed for date of service August 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the tomosynthesis mammogram 
provided on October 05, 2022. 
 
You asked the Plan to pay for interpretation of the tomosynthesis mammogram. You say that the service was 
medically necessary. The Plan denied your request. The Plan says an add-on code wasn't billed with an 
appropriate primary code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code G0279 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the interpretation of the tomosynthesis mammogram provided on October 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exercise equipment (A9300). 
 
You asked the Plan to pre-approve exercise equipment. You say that this equipment was ordered as medically 
necessary to help with your blood pressure and balance. The Plan denied your request. The Plan says exercise 
equipment is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve exercise equipment (A9300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sock aid tool. 
 
You asked the Plan to pre-approve a sock aid tool. You say that you really need this tool to help you put on 
your compression socks. The Plan denied your request. The Plan says the sock aid is not covered as it is not 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a sock aid tool.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee's medical needs can be met in 
the current facility. 
 
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 that the enrollee is stabilizing but is still somewhat unstable and should require only 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the 
enrollee is not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at 
the current facility is recommended. 
 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 LTACH services.