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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested treatment is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that to date there are no compelling data to suggest that proton therapy is 
superior to or more beneficial than intensity-modulated radiation therapy (IMRT)/image-guided radiation 
therapy (IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam 
therapy on clinical trials and to not routinely offer it to patients. The enrollee in this case has agreed to consent 
to a registry study which enrolls any patient receiving proton therapy for any disease. Notably, registry studies 
are not clinical trials or studies and have a much less rigorous development process. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 3, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99285 is bundled into payment for code 99223. 
 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 99285 
is a column II code to column I code 99223. 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 99285 billed for date of service July 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) purchased September 9, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that you would like to appeal the denied claim. The 
Plan denied your request. The Plan says the equipment was purchased from a provider who does not participate 
with Medicare. A continuous positive airwary pressure device is only covered when rented. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Also, per Medicare, a Continuous positive airway pressure (CPAP) device (E0601) is considered a 
rental item, meaning it must be rented and cannot be purchased. Therefore, we decided that the Plan does not 
have to pay for the continuous positive airway pressure (CPAP) device (E0601) purchased September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 99220. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
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 99220 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 
procedure code 99220 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99220 billed for date of service March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to reimburse you for dental services provided October 25, 2021.
You asked the Plan to pay additional reimbursement for dental services. The Plan denied your request. The Plan says your claim record shows that you had a crown placed on the same tooth on January 07, 2019. The Plan also stated your provider can balance bill you because he is a nonparticipating provider. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The dental Plan contract is clear regarding restorations to the same teeth and that the use of out of network dental providers may incur additional costs. Therefore, we decided that the Plan does not have for partial reimbursement for dental services provided October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (71045) provided to the enrollee on December 15, 2021 and billed under Claim A.
You asked the Plan to pay for services billed under Claim A. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan demonstrated that two sets of x-rays were rendered, and two sets were paid. The Plan states the claim number under appeal (Claim A) is a duplicate submission.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. The Plan provided documentation to show Claim A was previously paid. Based on this information, we decided that the Medicare rules payment of these services were not met. Therefore, we decided that the Plan does not have to pay for imaging services (71045) provided to the enrollee on December 15, 2021 and billed under Claim A.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service September 
12, 2022. 
 
You asked the Plan to pay for procedure code 99283. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 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 99283 
is a column II code to column I code 99284. 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 99283 billed for date of service September 12, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 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 the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a therapeutic CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for intrathoracic procedures (code 00562) 
provided on June 14, 2022. 
 
You asked the Plan to pay for anesthesia for intrathoracic procedures. The Plan denied your request. The Plan 
says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on June 28, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed items/services were provided twice on the same date. Based on 
this information, we decided that the Medicare rules for anesthesia for intrathoracic procedures have not been 
met. Therefore, we decided that the Plan does not have to pay for anesthesia for intrathoracic procedures  
(code 00562) provided on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) provided 
on February 23, 2022. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used in the treatment of 
peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Per LCD L33829, the requested PCD coded E0675 is not covered. 
Based on this information, we decided that Medicare rules for coverage of the PCD have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) 
provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the upper abdomen (code 00731) provided 
on February 4, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the upper abdomen. The Plan denied your request. 
The Plan says that this claim is a duplicate of a claim that has already been considered for payment. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has not provided proof of a 
duplicate claim. Based on this information, we decided that Medicare rules for coverage of anesthesia for 
procedures on the upper abdomen have been met. Therefore, we decided that the Plan has to pay for anesthesia 
for procedures on the upper abdomen (code 00731) provided on February 4, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
13, 2022. 
 You asked the Plan to pay for procedure code 76642. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76642 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76642 billed for date of service September 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is preparing for an extensive surgery 
coming up, so we are trying to approve admission to a skilled nursing facility for therapy to increase strength 
optimizer for the enrollees upcoming surgery. The Plan denied your request. The Plan says the enrollee is not 
suitable for skilled/long-term care facility but would be better suited for home health with personal care 
provider.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 76642 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 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service October 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transthoracic echocardiography (TTE) (93306) provided on 
March 2, 2022. 
 You asked the Plan to pay for the TTE. You say that this service is supported as billed and was medically 
necessary. The Plan denied your request. The Plan says this service was billed with a diagnosis of Z01.810 
(encounter for preprocedural cardiovascular examination) but there is no documentation of a planned 
procedure. Therefore, this service was provided as a screening but is not among those screening tests covered 
by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the TTE, was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
transthoracic echocardiography (TTE) (93306) provided on March 2, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF care was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required medical records.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The medical records provided show the care required at the time of the appeal was custodial. You did not require skilled therapy or skilled nursing care at an inpatient SNF level of care. Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72110 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code 72110. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 72110 is bundled into payment for code 72082. 
 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 72110 
is a column II code to column I code 72082. 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 72110 billed for date of service August 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is to rule out degenerative causes 
of memory loss. The Plan denied your request. The Plan says the medical records provided do not indicate that 
the enrollee meets the diagnostic criteria of both Alzheimer's disease and fronto-temporal dementia. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the PET scan of the brain is not medically necessary. Our physician reviewer found that the enrollee has been 
referred for a PET scan of the brain in the evaluation of dementia. According to the applicable NCD this 
service is only covered in individuals who meet diagnostic criteria for both AD and FTD. The enrollee's 
medical records indicate that they have been diagnosed (exclusively) with AD on a clinical basis. The enrollee 
is not noted to meet diagnostic criteria for FTD. In as much the base requirement of the NCD for this service 
would not have been met/satisfied. Therefore, this request cannot be said to meet criteria for coverage. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair and a raised toilet seat. You say that the requested items are 
medically necessary and should be covered. The Plan denied your request. The Plan says these items are not 
covered benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair and a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare 
offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair 
and a raised toilet seat.