Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the home exercise program is not an 
option for the enrollee as they have suffered from a stroke and have no use of their right arm. You say that the 
enrollee is in assisted living and is dependent upon a skilled physical therapist for critical exercises. The Plan 
denied your request. The Plan says 12 additional physical therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee can maintain their function with repetitive 
exercises and has regained their prior level of function. Therefore, continued skilled therapy is not 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided to the enrollee on April 4, 2022.
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that the technical charges are payable. The Plan denied your request. The Plan says that they pay for these services when the facility where the services were provided bills the Plan.
The Plan follows Medicare rules. Medicare rules say that when services are provided by a mobile unit, the mobile unit should bill the POS as the entity that is being served. Under Medicare rules, you should have billed POS 22-On Campus-Outpatient Hospital. Instead, you billed POS 15-Mobile Unit. This is not appropriate. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided to the enrollee on April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on October 24, 2022. 
 
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says you billed 
with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services have not been met. Specifically, this claim was billed with the office setting 
POS code. The records do not support that the sample was taken in an office setting. Therefore, we decided that 
the Plan does not have to pay for the imaging services provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
January 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documented interval history is 
not detailed. The documented medical decision making is not of high complexity. As such, the billing of CPT 
99233 is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
tooth #26 (D6057), and abutment supported porcelain/ceramic crown tooth #19 (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that you would like reconsideration due to 
coverage changes in the plan and you have been in the process for a long time. You also say that you are very 
anxious to learn that the Plan rules have changed. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 26, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment  includes 
placement tooth #26 (D6057), and abutment supported porcelain/ceramic crown tooth #19 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens and the anti-reflective coating provided 
on October 6, 2022. 
 
You asked the Plan to pay for the progressive lens and the anti-reflective coating. You say that your initial 
reimbursement does not represent the 80% of your expenses. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
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 does not cover upgrades. 
 
We looked at the file and the Plan's rules. Specifically, the services are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens and the anti-reflective coating 
have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens and the 
anti-reflective coating provided on October 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ibrance. 
 
You asked the Plan to pre-approve Ibrance. You say that the drug being requested is medically necessary for 
treatment of the enrollee's breast cancer. The Plan denied your request. The Plan says the requested drug is not 
covered under Part B. The Plan says that they do not administer Part D prescription drug coverage for the 
enrollee. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ibrance.  
 
Benefits for Ibrance may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the test is a Medicare covered service. The Plan 
denied your request. The Plan says the appropriate pathology code should be used. 
 
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 looked at the file and the rules. The records show that the testing specimen was from a prostate needle 
biopsy. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 88305 billed for date of 
service October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve POGO automatic test cartridges. 
 
You asked the Plan to pre-approve POGO automatic test cartridges. You say that you have diabetes and are 
currently using POGO automatic test cartridges. You say that you started treatment in August of 2022. You say 
that you are testing 3-times per day. The Plan denied your request. The Plan says the enrollee has not tried and 
failed the preferred product. The Plan says that no medical reason was provided by the prescriber against use of 
the preferred product. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to preferred brands of 
DME, as long as they ensure that the enrollee has access to all medically necessary DME products.  
 
We looked at the file and Medicare rules. The type of test cartridges you are requesting are not a LifeScan 
branded product and are non-preferred. The documentation provided did not demonstrate a reason why the requested non-preferred brand would be medically necessary or more medically appropriate than the preferred 
brand. Based on this information, we decided that Medicare rules for coverage of POGO automatic test 
cartridges have not been met. Therefore, we decided that the Plan does not have to pre-approve POGO 
automatic test cartridges.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve a guided tissue regeneration. You say that the services requested are 
medically necessary to restore oral health, esthetics, and function. The Plan denied your request. The Plan says 
this service is not covered on the enrollee's plan.  
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
guided tissue regeneration (D4266).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162). 
 
You asked the Plan to pre-approve genetic testing. You say that you have submitted medical records to support 
the reconsideration of the denied genetic testing. The Plan denied your request. The Plan says the requested 
services are not reasonable and 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Local Coverage Determination (LCD) Molecular Pathology Procedures L35000 states : 
"BRCA1 and BRCA2 genetic testing is considered medically necessary for a beneficiary with a current 
diagnosis or a personal history of a cancer associated with the BRCA mutation who meets one or more of the 
criteria found in the most recent version of the NCCN guidelines for Genetic/Familial High-Risk Assessment: 
Breast and Ovarian or other evidence based guideline addressing genetic testing, and the results will be used to 
benefit the individual tested in terms of potential to guide therapeutic decision making." Provided records in 
this case do not document the enrollee meets the above NCCN criteria for the requested testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA1 and BRCA2 genetic testing (81162).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a transthoracic echocardiogram for the enrollee.
You asked the Plan to provide coverage for these services. You say that at the time of the appeal, a transthoracic echocardiogram was medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denials using the Medicare Local Coverage Determination (LCD) for Transthoracic Echocardiography (TTE) L33577. The Plan requested a reopen and noted that the LCD used is not in the coverage jurisdiction. The Plan noted the medical records provided show the enrollee had a history of atrial fibrillation diagnosed in 2014. The most recent visit records no new cardiac complaints or concerns. This service was ordered for routine surveillance with no new cardiac complaints.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Based on the medical records provided, the enrollee did not have health indications that would require a transthoracic echocardiogram. Therefore, we decided that the Plan does not have to provide coverage for a transthoracic echocardiogram for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for surgical services received on October 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this was processed and denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provider appeal states that full medical records were enclosed. The plan has 
not provided any of these medical records to MAXIMUS for review. Therefore, we decided that the Plan has to 
pay for surgical services received on October 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 12, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient psychiatric services. 
 
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. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 the records do not indicate that the 
enrollee has been aggressive with peers or staff on the unit or has had any recent attempts at self-harm during 
the dates of service at issue. She is noted to be in no psychiatric distress and is eating and sleeping adequately. 
She is compliant with medications. She is not exhibiting any other significant psychosis or mania. She has had 
no psychiatric issues issues that require continued inpatient care beyond April 12, 2023 to April 17, 2023. She 
has chronic symptoms. The records do not support that continued inpatient care is 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 acute inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service October 6, 
2022. 
 You asked the Plan to pay for procedure code G0453. The Plan denied your request. The Plan says payment for 
code G0453 is bundled into payment for code 95887. 
 
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 G0453 
is a column II code to column I code 95887. 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 G0453 billed for date of service October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor (A4239). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the enrollee has type 2 
diabetes and it not treated with insulin. You also say the Freestyle Libre works best for the enrollee. The Plan 
denied your request. The Plan says the enrollee is not insulin treated with at least three daily injections. The 
enrollee does not meet approval for this CGM sensor. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor (A4239).