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

We decided that the Plan does not have to pay for genetic testing provided on October 6, 2021.
You asked the Plan to pay for these services. You say that this testing was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan states the rules specifically state this test is covered after a biopsy has been performed. The medical records show this was request prior to any biopsy being taken.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. Based on the medical records provided, those criteria were not met at the time of service. Therefore, we decided that the Plan does not have to pay for genetic testing provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic limb and its components represented by codes L5828, L5845, L5848, L5850, L5856, L5920, L5984, and L5987.

You asked the Plan to pre-approve these services. You say that the requested prosthesis is medically necessary in order for you to continue ambulating and in order to continue your life in the same way you have been for the last 20 years. The Plan denied your request. The Plan says that the criteria for coverage of a new prosthetic leg have not been met, but that you may meet criteria for a replacement of the prosthetic socket.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of these services have been met. There are insufficient medical records from the prescribing physician. The records from the prosthetist are inconsistent and have contradictory statements. The cost for replacement items or repair was also not included in the file. Without all this information we are unable to determine criteria for coverage has been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic limb and its components represented by codes L5828, L5845, L5848, L5850, L5856, L5920, L5984, and L5987.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not have a medical need for a group 3 power wheelchair with the requested power options/features.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a group 3 power wheelchair and accessories. Our Medical Director states that the available medical documentation in the case file does not support that this enrollee is at high risk for the development of a pressure ulcer and is unable to perform a functional weight shift, or utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed, or uses the power seating system as needed to manage increased tone or spasticity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on June 8, 2021.
You asked the Plan to pay for the laboratory services. You say that the services are not billed correctly. The Plan denied your request. The Plan says that there is no documentation that the sample was collected in the laboratory.
Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on June 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for non-emergent ambulance transport.
You asked the Plan to provide coverage for this transport. You say that at the time of the appeal this transport was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus administratively overturned the denial for no medical records. The Plan requested a reopen and provided the required medical records.
The Plan is correct in this case. Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Based on the medical records provided, there is no indication that you could not have been transported in a vehicle other than an ambulance or that travel in an ambulance was required for possibly immediate lifesaving conditions. Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to provide coverage for non-emergent ambulance transport.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GTC Hematology Profile provided to the enrollee on November 29, 2021.
You asked the Plan to pay for the GTC Hematology Profile. You say that you would like this claim reprocessed and approved for payment as this test was approved by the MolDX program and was medically necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the required unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. Based on this information, we decided that Medicare rules for coverage of the GTC Hematology Profile have not been met. Therefore, we decided that the Plan does not have to pay for the GTC Hematology Profile provided to the enrollee on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided to the enrollee on February 1, 2022.
You asked the Plan to pay for the testing. You say that you would like this claim to be paid. The Plan denied your request. The Plan says that there is no documentation of molecular pathology testing performed on a specimen collected by the laboratory.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was collected in the hospital. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided to the enrollee on February 1, 2022.
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 necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the records clearly show an inability to participate in an intensive rehabilitation program due to left side below the knee amputation.
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. The rules specifically state patients actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week.
Based on the medical records provided, you did not meet these criteria at the time of the request. 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 provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
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 the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes that though the enrollee was participating in skilled therapy sessions during the inpatient hospital stay, those sessions were less than two (2) hours per day of combined occupational and physical therapy. The records show the enrollee required minimal levels of assistance during these sessions.
The records show the enrollee's rehabilitation needs could have been met at a skilled nursing facility or home health therapy, as was documented by the Orthopedic Surgeon on September 13, 2022.
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, the enrollees continued physical and occupational therapy needs did not required an inpatient IRF level of care. Medicare rules for coverage of IRF care were not met at the time of the appeal. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home healthcare services provided to the enrollee from November 30, 2021, to December 29, 2021.
You asked the Plan to pay for the home healthcare services. You say that these services were medically necessary. The Plan denied your request. The Plan says the RAP claim form was invalid.
The Plan must follow Medicare rules. Medicare rules say that the RAP contains the same date in both the "from" and "through" date fields. We looked at the file and Medicare rules. The RAP form submitted does not contain the same date in both the "from" and "through" date fields. Based on this information, we decided that Medicare rules for coverage of the home healthcare services have not been met. Therefore, we decided that the Plan does not have to pay for the home healthcare services provided to the enrollee from November 30, 2021, to December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350 x4), and cone beam CT capture and interpretation with field of view of both jaws 
(D0367) provided on August 22, 2022. 

You asked the Plan to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350 x4), and cone beam CT capture and interpretation with field of view of both jaws (D0367). You say 
that you would like to be able to take back the money the Plan paid to the previous dentist and pay this bill 
where they were able to provide the services needed. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350 x4), and cone beam CT capture and 
interpretation with field of view of both jaws (D0367) provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on May 11, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have preventive care and you cleaning 
should be covered. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the bitewings are not covered by the Plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bitewings 
(D0274) provided on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you disagree with the denial. The 
Plan denied your request. The Plan says it would be more cost effective to replace the wheelchair rather than 
repair the chair. There is no way for the Plan to determine which repairs among the requested should be 
covered and which should not. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the repair quote is $2,553.50 and the enrollee 
had prior repairs totaling $1,827. The records also show that the total would be $4,380.50. The cost to replace 
the wheelchair is $3,705. Therefore, the enrollee does not meet criteria for repairs on this wheelchair. Based on 
this information, we decided that Medicare rules for coverage of power wheelchair repairs have not been met. 
Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), electrical stimulation 
(G0283), and the hot or cold packs therapy (97010) provided on September 15, 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 the services at issue are not covered by the 
Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110), electrical stimulation (G0283), and the 
hot or cold packs therapy (97010) provided on September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 3, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a robotic surgery operating room microscope for 
a cervical laminectomy. 
 
You asked the Plan to pre-approve robotic surgery technique. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the Plan does not offer separate coverage for robotic 
surgical systems. 
 
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 robotic surgery technique. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found robotic surgery microscopes and assistive devices are not medically needed in 
cervical spine surgery. They are considered experimental.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of robotic surgery technique have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of a robotic surgery operating room microscope for a cervical 
laminectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the inpatient services provided from June 14, 2022, to 
July 14, 2022, at the DRG originally billed. 
 
You asked the Plan to pay more for the inpatient services. You say that the enrollees admission was medically 
necessary. The Plan denied your request. The Plan says the enrollee has exceeded the out-of-network point of 
service benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the maximum benefit for out-of-network covered services is $5,000. 
 
The requested provider in this case is not a network provider with the Plan and the enrollees out-of-network 
POS benefits have been exhausted. Once the enrollees POS benefits have been exhausted, the Plan is not 
obligated to pay more. Therefore, we decided that the Plan does not have to pay more for the inpatient services 
provided from June 14, 2022, to July 14, 2022, at the DRG originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral periapical images (D0220), excision benign lesion 
up to 1.25cm (D7412) and gingival flap procedure including root planning (1-3 teeth/tooth per quadrant 
(D4341) provided on August 18, 2022. 
 
You asked the Plan to pay for dental services. You say that you were referred to the out-of-network provider 
for oral surgery. You were not aware that the Plan had to be contacted prior to surgery. Based on this 
information, you say you believe the services should be covered. The Plan denied your request. The Plan says 
these services are not covered under your Plan. 
 
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. Intraoral periapical images 
(D0220), excision benign lesion up to 1.25cm (D7412) and gingival flap procedure including root planning (1-
3 teeth/tooth per quadrant (D4341) are not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0220, D7412 and 
D4341 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for intraoral periapical images (D0220), excision benign lesion up to 1.25cm (D7412) and gingival flap 
procedure including root planning (1-3 teeth/tooth per quadrant (D4341) provided on August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on June 11, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says there 
was no submission of medical records for the June 11, 2022, date of service to support current procedural 
terminology code 99233. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the subsequent hospital care have been 
met. Medical records were not provided for the June 11, 2022, date of service. The record shows that the Plan 
asked for this documentation, but it was not received. Without this information, we are unable to determine if 
the services provided were medically necessary, or meet the criteria for coverage. Therefore, we decided that 
the Plan does not have to pay for the subsequent hospital care (99233) provided on June 11, 2022.