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

We decided that the Plan does not have to pay for the anterior instrumentation (22845) and the bone marrow
grafting (20930) provided during spinal surgery on June 22, 2021.
You asked the Plan to pay for the anterior instrumentation (22845) and the bone marrow grafting (20930)
provided during spinal surgery. You say that this claim should be paid. The Plan denied your request. The Plan
says while part of this claim was paid (22845), code 20930 is not supported. Maximus partially overturned the
Plans appeal stated the Plan did not provide documentation to show code 22845 was paid. The Plan requested a
reopen and submitted documentation to show code 22845 was paid on November 21, 2021.
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, we show that code 22855 was paid, and code 20930 has a status indicator
of "B" on the Physician Fee Schedule. This means that payment for this code is always bundled in payment for
other services. Medicare rules for coverage of this claim are not met. Therefore, we decided that the Plan does
not have to pay for the anterior instrumentation (22845) and the bone marrow grafting (20930) provided during
spinal surgery on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 24, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of lab tests have not been met. Specifically, this claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that at the time of the appeal, SNF services were
medically necessary. The Plan denied your request. The Plan says 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.
Our Medical Director looked at the case file and the reopen request. The medical records show you have a
history of heart disease, diabetes, hypertension, vascular disease, and bacteremia/discitis/osteomyelitis, who
was admitted to the hospital on September 8, 2021, with acute kidney injury, altered mental status, acute-onchronic
heart failure, and L1-L2 discitis/osteomyelitis. On September 9, 2021, the PT evaluation noted that you
refused physical therapy. The documentation does not support that you were ready for a skilled nursing facility
at the time of the request. The documentation does not support that it was medically reasonable and necessary
to provide skilled services on a "daily basis" on an inpatient basis, in a skilled nursing facility setting at the
time of the request. Medicare coverage criteria are not met.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pimecrolimus cream. 
 
You asked the Plan to pre-approve Pimecrolimus cream. You say that the chart notes provided support the 
medical need for Pimecrolimus cream. The Plan denied your request. The Plan says Pimecrolimus cream falls 
under Part D coverage and the enrollee does not have Part D coverage under this plan. 
 
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 Pimecrolimus cream.  
 
Benefits for Pimecrolimus cream 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance angiography (MRA) scan of the head 
(70544) provided on September 26, 2021. 
 You asked the Plan to pay for an MRA scan of the head. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
CPT code at issue is inclusive to another billed code. 
 
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 70544 
is a column II code to column I code 70551. 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 a magnetic resonance angiography (MRA) scan of the head 
(70544) provided on September 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) 
provided on January 28, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual 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 service provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
addition of a tooth to an existing partial denture (D5650) provided on January 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy services provided on April 19, 2021, billed 
with code 31622. 
 You asked the Plan to pay for the bronchoscopy services as billed. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says payment was approved for codes 
31624 and 31652; however, code 31622 is not payable when billed along with the approved codes. 
 
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 31622 
is a column II code to column I code 31652 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the bronchoscopy services provided on April 19, 2021, billed with code 31622.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee would benefit from the requested 
insoles. It is medically necessary that he is given the custom insole to begin his treatment instead of surgery. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure, by 
report (D5899) provided on February 28, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual 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 service provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified removable prosthodontic procedure, by report (D5899) provided on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a status indicator of 8. The file 
shows that the services were not performed in the inpatient setting.  
 
 
  
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479.  
 
  
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 15, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee has severe weakness and spinal 
stenosis transforaminal interbody fusion. The enrollee needs the shower chair to bathe safely. The Plan denied 
your request. The Plan says a shower chair is a convenience item and not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve auricular nerve stimulation. 
 
You asked the Plan to pre-approve auricular nerve stimulation. You say that nerve stimulation of the ear is 
medically necessary. The Plan denied your request. The Plan says Medicare guidance says electric nerve 
stimulation of the ear is considered a type of acupuncture. Electro-acupuncture of the ear is not a covered 
benefit under Medicare. 
 
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 auricular nerve stimulation. Our 
reviewer says that the requested nerve stimulation of the ear is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental/investigational 
approach. Therefore, the request is deemed 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 auricular nerve stimulation. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve auricular nerve stimulation (nerve stimulation of the ear).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on May 11, 2021. 
 
You asked the Plan to pay for the emergency services. You say that you feel that this should be covered 
because you needed emergency care. The Plan denied your request. The Plan says this IFED is not affiliated 
with a hospital. It was not enrolled as a temporary hospital under the 1135 waiver until after this date of 
service. As of the date the services were rendered, this provider was not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made to IFEDs that are not 
affiliated with a hospital unless the facility enrolls as a temporary hospital.   
 
We looked at the file and Medicare rules. This provider was not eligible to be paid by Medicare on the date of 
service at issue. Based on this information, we decided that Medicare rules for coverage of the emergency services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency 
services provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81479) 
provided December 29, 2020.  
You asked the Plan to pay for the genetic screening. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says this service does not meet the Medicare criteria for coverage. 
 
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 indicates that the cardiovascular genetic screening panel 
was initiated by the laboratory and not by the treating physician. The Plan also confirmed with the provider's 
office that their provider did not order this testing. Based on this information, we decided that Medicare rules 
for coverage of the genetic screening have not been met. Therefore, we decided that the Plan does not have to 
pay for the cardiac risk assessment genetic screening testing (81479) provided December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the unspecified preventive procedure, by 
report (D1999), the topical application of fluoride excluding varnish (D1208), the sales tax (D9985), and the 
core-build up, including any pins when required (D2950) provided from February 5, 2021, through  
December 6, 2021. 
 
You asked the Plan to issue reimbursement. 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 a covered benefit under 
your contractual policy. 
 
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 services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the unspecified preventive procedure, by report (D1999), the topical application of fluoride 
excluding varnish (D1208), the sales tax (D9985), and the core-build up, including any pins when required 
(D2950) provided from February 5, 2021, through December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81404, 
81479) provided May 6, 2021. 
 
You asked the Plan to pay for the genetic screening. You say that please find the attached appeal and 
reconsider the charges that were previously denied. The Plan denied your request. The Plan says this service 
does not meet Medicare coverage criteria. 
 
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. 
 
In this case the records indicates that the cardiovascular genetic screening panel was initiated by the laboratory 
and not the treating physician. The Plan confirmed with the doctor's office that the doctor did not order this 
service. The test at issue in this appeal, the genetic screening, 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 the cardiac risk assessment genetic screening testing (81404, 81479) provided May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for anesthesia services provided to the enrollee on August 13, 2021.
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 The Plan stated Medicare billing criteria were not met. Maximus overturned the Plans
denial for insufficient claim information to support the denial. The Plan requested a reopen and stated that this
claim denied because it was previously paid. The case file includes the claim image for both claims that shows
this service was billed under the same physician group. The guidelines state there are no modifiers associated
with NCCI that are allowed to be used with this PTP code pair; there are no circumstances in which both
procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers. Medicare billing criteria were not met. Therefore, we decided that the
Plan does not have to pay for anesthesia services provided to the enrollee on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of moderate sedation services (99153) 
provided on September 22, 2021. 
 
You asked the Plan to pay for additional moderate sedation services. You say that you have provided medical 
records to support the services at issue. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional moderate sedation services have not been met. Specifically, the record shows that 
procedure code 99153 was billed during an inpatient stay. It is inappropriate to report the code at issue 
separately. Therefore, we decided that the Plan does not have to pay for additional units of moderate sedation 
services (99153) provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, electronic connection, 
expandable controller with harness, and transit option for a power wheelchair (PWC). 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered. Medicare rules say that an expandable controller is used to control 
multiple power options. The rules state that for equipment to be covered, it must be appropriate and needed for 
use inside the home. 
 
The requested power seat elevation system and electronic connection are non-covered. The requested 
expandable controller with harness is not needed to control the approved power switches. The transit option is 
for use outside of the home and is not covered by Medicare. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation system, electronic connection, expandable controller with harness, and 
transit option for a power wheelchair (PWC).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a central motor evoked potential study (95939) and for 
limited needle electromyography (95870) provided on August 9, 2021. 
 
You asked the Plan to pay for a central motor evoked potential study and limited needle electromyography. 
You say that the codes at issue should not be considered bundling of services. The Plan denied your request. 
The Plan says rules for payment have not been met because the claim lines at issue are duplicates of prior 
claims that have been processed and paid.  
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a central motor evoked potential study and needle electromyography have not been met. 
Specifically, the Plan has documented that the claim lines at issue are a duplicate of prior claims that have been 
processed and paid. Therefore, we decided that the Plan does not have to pay for a central motor evoked 
potential study (95939) and for limited needle electromyography (95870) provided on August 9, 2021.