Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards (K0108x2) and a non-covered item or 
service (A9270). 
 
You asked the Plan to pre-approve side guards and non-covered item. You say that the requested wheelchair 
and accessories are needed to keep the enrollee safe, healthy, and independent. The Plan denied your request. 
The Plan says side guards do not serve a medical purpose and A9270 is a non-covered item per Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   

The side guards in this appeal do 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. Code A9270 is a non-
covered item per Medicare and does not meet coverage criteria. Therefore, we decided that the Plan does not 
have to pre-approve side guards (K0108x2) and a non-covered item or service (A9270).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 8, 2022 and billed under Claim A with code 83789.
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. Maximus overturned the Plans denial for insufficient code information in their denial. The Plan requested a reopen and provided additional information. The Plan noted this claim denied because this service does not meet the criteria for the category under which it was billed. This code was billed with code G0480, which is for definitive testing of urine samples for 1-7 drug classes. The Plan paid code G0480. These procedure codes specifically include mass spectrometry and chromatography. The provider billed code 83789 with modifier 59 to indicate that a separate and distinct chromatography and mass spectrometry was performed, and that code 83789 represents validity testing to confirm the results of the drug tests performed.
However, the Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. In addition, the records do not support testing of a non-drug analyte as indicated in the code description.
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, this claim could not be paid as billed due as code 83789 could not be paid separately when code G0480 is also paid. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 8, 2022 and billed under Claim A with code 83789.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision or removal of implanted spinal neurostimulator 
pulse generator or receiver (63688) provided July 8, 2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that please review the attached medical records 
which document the medical necessity need for surgical assistant and reprocess the denied charges for payment. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or surgical 
team are not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 63688. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
outpatient surgery have not been met. Therefore, we decided that the Plan does not have to pay for the revision 
or removal of implanted spinal neurostimulator pulse generator or receiver (63688) provided July 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nano synthetic graft allograft. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Nano synthetic allograft 
is considered experimental in nature, as more research is needed to support its use. The services are 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 a Nano synthetic graft allograft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not address the notes in the medical records that indicate this enrollee's ability to participate in intensive therapy was described as limited by the hospital physical therapist, given their impaired strength, endurance, activity/standing tolerance noted during a short therapy session, as well as confusion and safety awareness issues.
Additionally, the assertion that the enrollee requires "close medical monitoring" due to complications does not consider the limitation that the IRF benefit is not to be used as an alternative to completion of the full course of treatment in the referring hospital.
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. Based on the medical records provided, at the time of the appeal, the enrollee did not meet all of the coverage criteria required by Medicare for admission. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 64447. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 64447 is bundled into payment for 
code 01402. 
 
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 64447 
is a column II code to column I code 01402. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 64447 billed for date of service November 9, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and a BMP allograft. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no specific indication provided 
to support the request for bone marrow aspirate for the approved surgery. There is a lack of large-volume, long-
term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate, in 
this case, is not medically reasonable or necessary.  
 
There is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this 
request has beneficial outcomes compared with conventional treatment. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Infusion BMP allograft, in this case, is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate and a BMP allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services by 
physician or other qualified health care professional (96133x2). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that the extra time is needed to write 
this report and present the report to the enrollee for feedback. Because of the nature of the enrollee's problem, 
this extra time is needed to thoroughly write and access in this evaluation. The Plan denied your request. The 
Plan says the provider has documented the testing requested and has clearly outlined the need for 10 hours (14 
units). The request for 10 hours (14 units) of testing is approved as medically necessary. There is no 
documentation why this extended 
testing time is 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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollees documentation shows the enrollee continues to drive and has 
been showing mild distraction and minimal disorientation. He has had mood lability and continues to have 
difficulty with recall of names, dates, events, appointments, and short-term memory. Utilizing the criteria for 
neuropsychological testing that this testing is intended to diagnose and characterize the neurocognitive effects 
of medical disorders that impinge directly on or indirectly on the brain including detection of neurologic 
disease based on quantitative assessment of neurocognitive abilities, differential diagnosis between 
psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central nervous system 
disorders, neurocognitive monitoring of recovery or progression of central nervous system disorders or 
assessment of neurocognitive function for the formulation of rehabilitation and/or management strategies 
among individuals with neuropsychiatric disorders, the information provided does not discuss the need for 
extra interpretation in aiding diagnosis and treatment. Based on the information provided and utilizing LCD 
L34646, this enrollee does not require additional interpretation of neuropsychological testing as being not 
medically necessary or reasonable as information presented is sufficient for the decision-making process for 
treatment of 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 neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing evaluation services by physician or other 
qualified health care professional (96133x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87633 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 87633. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this service is not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panels which test for more 
than 5 respiratory pathogens performed in a Part B outpatient setting are considered not medically reasonable 
and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87633 have not been met. Specifically, the panel at issue in this case included more 
than five respiratory pathogens. Therefore, we decided that the Plan does not have to pay for procedure code 
87633 billed for date of service October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 19, 2022, billed with 
codes 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that the attached documents clinically support 
the service. Please review the attached physicians requisition form, lab results and clinical notes and reconsider the claim for payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 19, 2022, billed with codes 81321 and 81351.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not takin into consideration that the enrollee's ability to participate in intensive therapy was described as limited by the hospital physical therapist, given their decreased strength/activity tolerance, fatigue, weakness, dizziness with transitional movements and multiple episodes of incontinence with mobility, as well as orthostatic hypotension and stage IV cancer treatment.
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.
Based on the medical records provided, at the time of the appeal, the enrollee did not meet all of the Medicare required coverage criteria for IRF admission. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service December 6, 
2022. 

You asked the Plan to pay for procedure code 76775. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76775 is bundled into 
payment for code 93976. 
 
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 76775 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76775 billed for date of service December 6, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve the acute inpatient hospital level of care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met. Our physician reviewer 
found the enrollee is approved for shoulder surgery that is not on the inpatient-only list. The records do not 
support a reasonable expectation that the enrollee will require at least two midnights of inpatient hospital care 
for the approved procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient hospital level of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel 
provided on January 5, 2022. 
 
You asked the Plan to pay for the PCR respiratory panel. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered.  
 
We looked at the file and Medicare rules. Review of the file shows that the services rendered were for six or 
more pathogens and therefore, not covered. Based on this information, we decided that Medicare rules for 
coverage of the PCR respiratory panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the polymerase chain reaction (PCR) respiratory panel provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sinus augmentation with bone or bone substitutes via a 
lateral open approach (D7951) and the bone replacement grafts for ridge preservation-per site (D7953 x 2) 
provided on July 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
enrollee's supplemental dental policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sinus 
augmentation with bone or bone substitutes via a lateral open approach (D7951) and the bone replacement 
grafts for ridge preservation-per site (D7953 x 2) provided on July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (Tempus nP Panel) provided to the enrollee on March 30, 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 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 criteria. The Plan noted there are insufficient medical records submitted to show this testing was necessary.
The Plan is correct in this case. 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. There are insufficient medical records submitted to show this testing was medically necessary.
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan does not have to pay for lab services (Tempus nP Panel) provided to the enrollee on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting provided on November 3, 2022. 
 
You asked the Plan to pay for the contact lens fitting. You say that this was your annual routine eye 
examination, and you are requesting reimbursement. The Plan denied your request. The Plan says the benefit 
has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $100 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 of the allowance on April 29, 2022, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
contact lens fitting have not been met. Therefore, we decided that the Plan does not have to pay for the contact 
lens fitting provided on November 3, 2022.