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

 
We decided that the Plan does not have to pay for the services (64447) provided on November 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 64447 is not supported in the medical record. Specifically, this code was not billed with 
an appropriate anatomic modifier. 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 pay for the services 
(64447) provided on November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept device. 
 
You asked the Plan to pre-approve an Intracept device. You say that the requested Intracept device is medically 
necessary. The Plan denied your request. The Plan says the requested Intracept device is not medically 
necessary. 
 
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 an Intracept device. Our reviewer says 
that the requested Intracept device is not medically necessary. Our physician reviewer found the Intracept 
procedure is experimental for low back pain. More research is needed to show safety and efficacy. The 
requested Intracept device is not medically necessary for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept device.
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 IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says medical necessity rules for IRF care have 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 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 that the complexity of your nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cervical bilateral epidural steroid injections (62321) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that the medical records provided should 
support the necessity of the requested service. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the cervical bilateral epidural steroid injections (62321) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injections (64494) provided on September 27, 
2021.  You asked the Plan to pay for the facet joint injections (64494). You say that the attached medical records 
support the level of service provided to the patient. You say that both 64494 lines should be reconsidered for 
payment. The Plan denied your request. The Plan says CPT code 64494 exceeded the allowable units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the facet 
joint injections (64494) have not been met. Therefore, we decided that the Plan does not have to pay for the 
facet joint injections (64494) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the LTACH services provided from August 14, 2021, to September 24, 
2021. We decided that the Plan does not have to pay for the LTACH services provided from September 25, 
2021, to September 29, 2021.  
 
You asked the Plan to pay for LTACH care. You say that these services were pre-approved up to September 
24, 2021, and you would like a partial payment of this claim up to this date. You also say the last covered day 
was billed with modifier 47 to indicate this fact. The Plan says that these services need to be billed as separate 
claims in order for the covered days to be paid. 
 
We decided that the Plan has to pay for the LTACH services provided from August 14, 2021, to 
September 24, 2021.  
 
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. Specifically, the record shows that the LTACH services were pre-approved from 
August 14, 2021, to September 24, 2021, per the letter dated September 23, 2021. Services were provided 
beyond this date and the billing rules were followed with modifier 47. The Plan denied this claim and stated 
that this claim needed to be split into two in order for payment to be made. The Plan has not provided any 
citation or evidence to support their claim that claims must be split in order to receive payment. Therefore, we 
decided that the Plan has to pay for the LTACH services provided from August 14, 2021, to September 24, 
2021.  
 
We also decided that the Plan does not have to pay for the LTACH services provided from September 
25, 2021, to September 29, 2021. 
 
 
 Based on the appeal submitted, you understood that these dates would not be covered by the Plan as they were 
not pre-approved, and you billed these services to show that they would not be covered. It does not appear that 
you are specifically appealing these dates; therefore, they will remain non-covered, and the Plan does not have 
to pay for the LTACH services provided from September 25, 2021, to September 29, 2021. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX for the enrollee. 
 
You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary. The Plan denied your 
request. The Plan says that documentation received does not show member has tried and failed one of the 
preferred medications. 
 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 Supartz FX. Our reviewer says that 
Supartz FX is not medically reasonable and necessary. The record indicates that the enrollee has osteoarthritis 
of the right knee. The requested medication is a new start. The provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. 
Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TENEX procedure, percutaneous ultrasonic ablation of 
soft tissue (24999). 
 
You asked the Plan to pre-approve the TENEX procedure. You say that the TENEX percutaneous debridement 
system allows for a much safer procedure to be performed with less morbidity and potentially even greater 
success rates. The Plan denied your request. The Plan says this procedure is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENEX procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TENEX procedure, percutaneous ultrasonic ablation of soft tissue (24999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provide to the enrollee on May 7, 2021.
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 Medicare billing criteria were not met. Maximus overturned the Plans
denial for insufficient claim information. The Plan requested a reopen and provided additional claim
information. The Plan states per National Correct Coding Initiatives (NCCI), a Procedure to Procedure (PTP)
edit exists between 99291 and 93042. This PTP edit has a modifier indicator of 0, which indicates there are no
modifiers that are allowed with this PTP code pair.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case the claim
cannot be paid as billed due to an error with the reported modifier. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services
provide to the enrollee on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 5 and 7. 
 
You asked the Plan to pre-approve the pontics. The Plan denied your request. The Plan says the pontics are not 
medically necessary because based upon the x-rays your dentist sent, the information provided does not meet 
criteria for bridge coverage. 
 
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. The Plan covers the pontics 
when the services are medically necessary and reasonable.  
 
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 pontics. Our reviewer says that 
given the Plan criteria for fixed bridgework, there would be no necessity for the requested pontics which would 
become part of a five unit bridge. Our physician reviewer found in this instance there is more than one missing 
tooth in the upper arch, with at least tooth #'s 5, 7, 10, and 11 missing as seen in the x-rays. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pontics (D6240) for tooth #'s 5 and 7.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic crown (D2740) for tooth #14. 
 
You asked the Plan to pre-approve a crown. You say that the current crown is over 10 years old, and the 
porcelain is broken causing bleeding, pain and trapped food. The Plan denied your request. The Plan says that 
the documentation does not support that the existing crown needs to be replaced. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable. 
 
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 a crown. Our reviewer says that the 
criteria for coverage of a replacement crown are met in this case. Our physician reviewer found that the 
documentation provided indicates the porcelain of the crown has fractured allowing for food impaction; the 
provider notes that there is gingival bleeding from the food trap. The crown was noted as being at least ten 
years old. The x-ray view shows the marginal area intact, however the photos indicate food trapping areas 
where the contacts of the teeth do not line up sufficiently to prevent this food trap. Although the margins of the 
crown appear intact, part of the purpose of the crown is to allow for tooth and gingival health. In a situation 
where the periodontal tissues will be negatively affected by the damaged crowns, the only method of repairing 
this is to replace the damaged crown. The need for the crown has been supported by the damaged porcelain 
causing a food impaction issue that will negatively affect the periodontium. There is medical necessity for a 
crown replacement in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a porcelain/ceramic crown (D2740) for tooth #14.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, socket insert, Symes 
(L5654), an addition to lower extremity, Symes type, posterior opening socket (L5634), an addition, 
exoskeletal system, below knee, ultra-light material (L5785) and an addition to lower extremity, test socket, 
below knee (L5620). 
 
You asked the Plan to pre-approve a prosthesis for your left leg. You say that a brace does not fulfill your 
needs and lifestyle. The Plan denied your request. The Plan says the requested items exceed your needs and 
cannot be covered by the Plan. 
 
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. The records show 
that you do not have a Symes, leg amputation. The records also show that you have a partial foot amputation. 
We confirm that the requested items exceed your needs and cannot be covered. Therefore, we decided that the 
Plan does not have to pre-approve an addition to lower extremity, socket insert, Symes (L5654), an addition to 
lower extremity, Symes type, posterior opening socket (L5634), an addition, exoskeletal system, below knee, 
ultra-light material (L5785) and an addition to lower extremity, test socket, below knee (L5620).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on April 20, 2021,
and billed under code 99214.
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 this service was previously paid. Maximus overturned the Plans denial for insufficient
claim information. The Plan requested a reopen and provided the required claim information. The Plan
provided documentation to show these services were previously paid.
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, there is
insufficient medical record documentation submitted to show this was a separate and distinct service. Medicare
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to
pay for medical services provided to the enrollee on April 20, 2021, and billed under code 99214.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve core buildups, including any pins when required (D2950) for tooth 
#'s 29 and 31, retainer crowns (D6751) for tooth #'s 29 and 31, and a pontic (D6241) for tooth #30. 
 
You asked the Plan to pre-approve the core buildups, retainer crowns, and pontic. The Plan denied your 
request. The Plan says that a bridge is only allowed if the enrollee is missing one front tooth. The Plan also says 
that the x-rays do not show that tooth #'s 29 or 31 have a lot of tooth missing from a cavity or have a lot of 
damage from being broken. 
 
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. The Plan covers the core 
buildups, retainer crowns, and pontic when the services are medically necessary and reasonable. 
 
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 core buildups, retainer crowns, and 
pontic. Our reviewer says that the documentation provided meets the criteria for coverage for core buildups 
(D2950) and a replacement bridge using teeth #29 and 31 as abutment retainers (D6751) in replacing missing 
tooth #30 with a pontic (D6241). Our physician reviewer found the documentation indicates recurrent caries on 
the mesial surface of tooth #31. Our reviewer also found that removal of the current bridge is medically 
reasonable and necessary, and a replacement bridge would be the standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the core buildups, retainer crowns, and pontic have been met. Therefore, we 
decided that the Plan has to pre-approve core buildups, including any pins when required (D2950) for tooth #'s 
29 and 31, retainer crowns (D6751) for tooth #'s 29 and 31, and a pontic (D6241) for tooth #30.  
 
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.