Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that imaging that is sensitive in detecting local recurrence 
is of utmost importance in case the enrollee would need salvage treatment. The Plan denied your request. The 
Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the notes describe a 
residual vulvar mass which is better seen on the MRI study of 11/22/21. It seems reasonable to assume both 
exams will be necessary to restage the patient at this time since lymph nodes and residual tumor were better 
seen on the MRI of November than on the PET/CT. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the pelvis for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311) between the power 
tilt seating system/power elevating legrests and the main drive control. 
 
You asked the Plan to pre-approve the electronic connection. You say that this should be approved as 
requested. The Plan denied your request. The Plan says the wheelchair and all accessories were approved aside 
from the electronic connection to allow for control of the power seating actuators from the main joystick. 
 
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 the electronic connection. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested accessories are not medically necessary as she does have use of her hands and can 
operate and control the power options using the switches that are included in the basic wheelchair.  There is no medical need for these to be operated from the main drive control. 
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection (E2311) between the power tilt seating 
system/power elevating legrests and the main drive control.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (37224) provided May 3, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 37224 is Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral. 
 
We find that CPT code 37224 is not supported in the medical record. Specifically, the operative report does not 
support the billed service. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (37224) provided May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology, gross and microscopic examination 
(88305) special stain including interpretation and report (88312) provided on November 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you work with a number of doctor groups 
who are participating providers and use your lab services exclusively. Patients does not come to the lab so they 
are not using out of network benefits as the doctor's send the specimens to process. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for surgical pathology, gross and microscopic 
examination (88305) special stain including interpretation and report (88312) provided on November 18, 2021 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing 
x-ray (D0274) provided on November 10, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you were advised prior to the date of service 
that you were covered. You also say that you were not informed about the in network or out of network 
provider eligibility. The Plan denied your request. The Plan says dental services received out of network are not 
covered. 
 
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, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-ray (D0274) provided on November 10, 2021, by the out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (29827, 29828, 29824, 29826) provided on 
November 11, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 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 use of codes 29827, 
29828, 29824, and 29826 is not supported by the records provided. Our reviewer found that for code 29827, the 
operative report does not include enough documentation to confirm a rotator cuff repair was performed. The 
operative report indicates a rotator cuff repair, however, how the repair was performed cannot be verified. For 
code 29828, the operative report does not describe a biceps tenodesis procedure. The operative report states a 
tenodesis was performed using sutures, however the report does not include the description of the procedure to verify this procedure has been performed. For code 29824, the operative report does not include enough 
documentation to verify this procedure has been performed. For code 29826, the operative report does not 
document decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, 
arch) release. 
 
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 the services (29827, 29828, 29824, 29826) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310) provided by an out-of-
network provider on December 15, 2021. 
 
You asked the Plan to pay for a diagnostic consultation. You say that these services were necessary. The Plan 
denied your request. The Plan says D9310 is not a covered benefit. 
 
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 pay for a 
diagnostic consultation (D9310) provided by an out-of-network provider on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) and core buildup, including any pins when required (D2950) provided January 10, 2022. 
 
You asked the Plan to pay for the root canal and core buildup. You say that you dentist advised that you have 
these services. The Plan denied your request. The Plan says these services are not covered under your benefits. 
 
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 pay for the 
endodontic therapy, molar tooth (excluding final restoration) (D3330) and core buildup, including any pins 
when required (D2950) provided January 10, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on April 16, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan states that this claim denied because the reported taxonomy is not Medicare Certified. The claim shows
the provider has billed with an NPI that is not found listed in the Medicare Provider and Supplier Taxonomy
Crosswalk.
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 taxonomy code.
In this case, the taxonomy code reported is not showing as a valid taxonomy code. Medicare rules for coverage
of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical
services provided to the enrollee on April 16, 2021.
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 this is medically necessary. The Plan 
denied your request. The Plan says the services can be provided in another setting. 
 
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 in this case, the enrollee was admitted for elective cholecystectomy that was 
complicated by small bowel perforation enterocutaneous fistula. The record indicates that the enrollee is 
improving but still requires ongoing acute care services. The enrollee continues to receive acute care services 
and these have not been denied. The medical record does not indicate that the enrollee requires services that he 
is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fusion of spine with a metal spacer. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental procedures are not covered. 
 
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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that interspinous process stabilization devices remain experimental. More research is needed to show 
safety and efficacy. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fusion of spine with a metal spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder arthroscopy with rotator cuff repair. 
 
You asked the Plan to pre-approve the requested shoulder procedure. You say that you need this treatment for 
your shoulder injury. The Plan denied your request. The Plan says the records do not support the medical 
necessity of surgical intervention at this time. 
 
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 the requested shoulder procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a female who presented with right shoulder pain. She has had pain 
for 6 months. She has significant rotator cuff tendinitis, with a likely full-thickness tear of her supraspinatus. 
She also has subacromial impingement and a hypertrophic acromioclavicular (AC) joint, with significant 
inflammation and swelling. The right shoulder exam reveals deformity of the AC joint, with an elevation of the 
distal clavicle.  
 
 However, detailed documentation is not evident regarding a rotator cuff tear on the radiologists read of the 
magnetic resonance imaging (MRI) scan dated 1/10/22. The provider notes likely full-thickness rotator cuff 
tear with AC joint arthritis and impingement. However, the official read from the radiologist demonstrates 
mild supraspinatus and infraspinatus tendinosis with no corresponding tendon tear identified. Without 
(reasonably consistent) imaging corroboration of pathology to be treated with surgery, the request cannot be 
supported. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, requested right shoulder arthroscopy 
with rotator cuff repair, in this case, is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested shoulder procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a shoulder arthroscopy with rotator cuff repair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4260), osseous tissue material (D4265), 
and a guided tissue regeneration (D4266) provided by an out-of-network provider on October 8, 2021. 
 
You asked the Plan to pay for osseous surgery, osseous tissue material, and a guided tissue regeneration. You 
say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the services that 
were rendered are not covered dental benefits. 
 
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 osseous surgery (D4260), osseous tissue material (D4265), and a guided tissue regeneration (D4266) provided by an out-of-network provider on October 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0429-RW) provided on September 
12, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee received ET3 (Emergency 
Triage, Treat, and Transport) telehealth intervention services, and this modifier was used correctly. The Plan 
denied your request. The Plan says this procedure code is inconsistent with the modifier used. The Plan also 
says that ET3 Telehealth is a voluntary five-year payment model that will provide greater flexibility to 
ambulance care teams to address emergency health care needs of "traditional Medicare Fee-for-Service" 
beneficiaries following a 911 call. It does not apply to Medicare Advantage Plans. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find 
that CPT code A0429-RW is not supported in the medical record. Specifically, W is not a valid destination 
modifier for this service. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services (A0429-RW) provided on September 12, 2021.
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 transfer to a LTACH is medically 
necessary. The Plan denied your request. The Plan says the patient's needs are being met at the current acute 
setting. With additional time in the current setting, clinical stability can be ensured such that appropriate lower 
level of care can be determined. 
 
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 the patient appears to be more stable and improving which should only require short-
term additional acute care services that can be safely administered at the current facility until appropriate for a 
lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Transfer to a lower level of care may be considered when treatment has completed.  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat, grabbing device, and shoehorn for 
the enrollee. 
 
You asked the Plan to pre-approve a raised toilet seat, grabbing device, and shoehorn. You say that a raised 
toilet seat, grabbing device, and shoehorn are medically necessary for the enrollee. The Plan denied your 
request. The Plan says these items are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  Medicare statutorily excludes coverage for raised toilet seats, grab bars and self-help devices. 
Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat, grabbing device, and 
shoehorn for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spectrometry testing (83789) provided on September 29, 
2021. 
 
You asked the Plan to pay for spectrometry testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this should not be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory 
performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine 
specimen is not adulterated, this testing is not separately billed. 
 
 
 We find that CPT code 83789 is not supported in the medical record. Specifically, the records show that this 
testing was performed as validity testing for the specimen used for drug testing. Based on this information, we 
decided that Medicare rules for coverage of spectrometry testing have not been met. Therefore, we decided that 
the Plan does not have to pay for spectrometry testing (83789) provided on September 29, 2021.