Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on April 13, 2021
and billed under code 72074-26.
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 Medicare billing criteria are not met.
Maximus overturned the Plans denial for insufficient claim information to substantiate the denial. The Plan
requested a reopen and provided additional claim information. The Plan provided documentation to show this
service was previously paid for the same date of service for the same enrollee. There was no documentation
provided with the second claim to show these were separate and distinct services from those already billed and
paid for by the Plan.
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 service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed. Medicare billing criteria
were not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the
enrollee on April 13, 2021 and billed under code 72074-26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the lumbar spine (72158) and injection of gadolinium-based magnetic resonance contrast agent (A9579) provided on May 13,
2020.

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 Medicare billing criteria were not met as code 72158 was previously paid. Maximus partially overturned the Plans denial for insufficient information in the case file regarding the payment of code 72158. The Plan requested a reopen and provided proof of that payment.

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 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 magnetic resonance imaging (MRI) of the lumbar spine (72158) and injection of gadolinium-based magnetic resonance contrast agent (A9579) provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; femoral nerve (CPT code 64447) provided to the enrollee on April 27, 2021.
You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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. Review of the file shows the code was denied appropriately as it was missing an anatomical modifier. CPT code 64447 is a bilateral code as indicated by the bilateral indicator of "1" on the Medicare Physician Fee Schedule.
This means that a modifier is required to indicate if the procedure was bilateral and conducted on both sides of the body, or an LT/RT modifier to indicate only the LT (left side) or RT (right side) of the body. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; femoral nerve (CPT code 64447) provided to the enrollee on April 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the psychotherapy (90837) rendered by the
out-of-network (OON) provider on September 16, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 issue reimbursement care from out-of-network providers only in cases involving
emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to issue reimbursement for this service. Therefore, we
decided that the Plan does not have to issue reimbursement for the psychotherapy (90837) rendered by the out-
of-network (OON) provider on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 30, 2021.
You asked the Plan to pay for the dental service. You say that you received these services in February 2020. You say that you were not able to find the same dentist. You say that you had to find a new dentist. You also say that you do not understand why this is not covered. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 36 months. The Plan also says that the frequency limit has been exceeded.
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 and comprehensive oral evaluation is
listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on February 24, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Optimizer Smart IPG (CPT code 0408T), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an exhaustive review of the current medical literature pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy.
Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, our physician reviewer would not consider the CCM system to be medically necessary in this 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve Optimizer Smart IPG (CPT code 0408T), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found that you have right knee pain. You were seen in the emergency room (ER) and imaging revealed pain related to arthritis and Baker's cyst on the back of the knee. There is no record of previous conservative treatments and imaging has not been completed. There is no orthopedic consultation with surgery or injections being rejected or tried and failed. There is no documentation of red flag signs or symptoms suggesting a need for MRI at this time. The MRI is therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Genomic Unity Exome Plus Analysis provided on
February 5, 2021.
You asked the Plan to pay for the Genomic Unity Exome Plus Analysis. You say that this was a medically
necessary test ordered by the treating provider. The Plan denied your request. The Plan says this is a screening
test that cannot be covered by Medicare.
The Plan follows Medicare rules. Medicare rules say that molecular pathology testing may be covered when the
criteria listed in the Medicare rules section of this letter are met.
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 Genomic Unity Exome Plus Analysis.
Our reviewer says that the testing provided is not considered reasonable and necessary in this case. Our
physician reviewer found the member has a 40-year history of ataxia symptoms. It is otherwise unclear from
the records which were provided for review with this case how the services provided would be useful in the
management of the member's condition. The scope of the testing would also involve testing for conditions that
is not applicable to this condition. In this setting it cannot be concluded that the testing under review would
have been reasonable and necessary as defined by the LCD.
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 Genomic Unity Exome Plus Analysis have not been met. Therefore, we
decided that the Plan does not have to pay for the Genomic Unity Exome Plus Analysis provided on February
5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin grafts (15275 and 15276) provided on June 22,
2021.
You asked the Plan to pay for the skin grafts (15275 and 15276). The Plan denied your request. The Plan says
procedure codes 15275 and 15276 are not supported by the medical records submitted.
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 15275 is application of skin substitute graft to face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to
100 sq cm; first 25 sq cm or less wound surface area.
The CPT Code Manual definition of code 15276 is application of skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq
cm; each additional 25 sq cm wound surface area, or part thereof (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 the skin grafts (15275 and 15276). Our reviewer says that the
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that
the documentation does not support an application of skin substitute graft was performed, therefore this
procedure cannot be performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skin grafts (15275 and 15276) have not been met. Therefore, we decided
that the Plan does not have to pay for the skin grafts (15275 and 15276) provided on June 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastrointestinal tract imaging (91110).
You asked the Plan to pre-approve the gastrointestinal tract imaging. The Plan denied your request. The Plan
says the capsule endoscopy (91110) that you are requesting does not meet the requirements for approval.
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is
considered medically reasonable and necessary when certain conditions have been met. The Medicare rules
also say that a colon capsule endoscopy is not medically reasonable and necessary for patients with known or
suspected gastrointestinal obstruction, stricture, or fistula.
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 gastrointestinal tract imaging. Our
reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the
record indicates that the enrollee has had multiple episodes of bowel obstruction with no evidence of adhesions
or strictures on laparoscopy. Our reviewer found that the record indicates and magnetic resonance enterography
was normal. Our physician reviewer also found that the record does not indicate that the enrollee has a
diagnosis that is a covered indication.
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 gastrointestinal tract imaging have not been met. Therefore, we decided that
the Plan does not have to pre-approve a gastrointestinal tract imaging (91110).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (CPT code 90834) provided from August
4, 2021, through September 13, 2021, by a LMHC.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says the services provided by a mental health counselor are
not covered by your plan.
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 services have not been met. This service is not covered as the
provider is a mental health counselor and not eligible for payment by the health plan or original Medicare.
Therefore, we decided that the Plan does not have to pay for the psychotherapy (CPT code 90834) provided
from August 4, 2021, through September 13, 2021, by a LMHC.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SPRINT PNS system for the enrollee.
You asked the Plan to pre-approve the SPRINT PNS system. You say that a SPRINT PNS system is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial and stated that although this request is not for an implantable nerve stimulator
device, a trial of a peripheral device is reasonable to determine if an implantable device would be reasonable
and effective. The Plan requested a reopen and stated that the SPRINT PNS system does not involve a receiver
unit that is implanted under the skin and the electrode lead placement for SPRINT PNS is temporary, not
involving implantation surgery. Therefore, the device does not meet National Coverage Determination (NCD)
for Electrical Nerve Stimulators (160.7) criteria for covered peripheral nerve stimulators.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for nerve stimulators. While it is understood the Sprint PNS system may be beneficial for the enrollee, it is not
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the SPRINT PNS
system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacral lateral branch nerves (L5-S3) (CPT code(s): 64636, 64635, 64625), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide variation in efficacy described in the literature. Therefore, the request is considered not medically reasonable or necessary. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacral lateral branch nerves (L5-S3) (CPT code(s): 64636, 64635, 64625), for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor (CPT code
33285), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says there is no clinical evidence to support the medical necessity of this examination or that
the enrollee meets Medicare criteria for a subcutaneous cardiac rhythm monitor.
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 service. Our physician reviewer
found while the enrollee has a history of atrial fibrillation/flutter, there is no documentation provided to suggest
a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an implantable loop
recorder (ILR). In summary, there is insufficient documentation to support the medical necessity for insertion
of an ILR in this patient's clinical management.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve a subcutaneous cardiac rhythm monitor (CPT code 33285), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of lower extremity arteries or arterial bypass
grafts; complete bilateral study (CPT code 93925) provided to the enrollee on May 9, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not authorized because screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, the service, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (CPT code 93925)
provided to the enrollee on May 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs an adjustable hospital bed. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99223) provided on March 29,
2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the charges processed and paid under
the provider member's regular physician.
The Plan must follow Medicare rules. Medicare rules say that that the patient's regular physician or may
submit the claim, and receive the Part B payment, for covered visit services which the regular physician or
physical therapist arranges to be provided by a substitute physician or physical therapist on an occasional
reciprocal basis.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the subsequent hospital care have not been met. Specifically, the record indicates that these charges
were initially billed by the member's regular physician with modifier Q5, indicating that these services were
rendered by a substitute physician. This provider furnished the services as a substitute physician in lieu of the
attending physician and these claims have been processed and paid by the Plan. Therefore, we decided that the
Plan does not have to pay for the subsequent hospital care (99223) provided on March 29, 2020.