Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99601) provided December 2, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the code billed is not eligible for payment. 
 
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 find that CPT code 99601 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "I" and is not eligible for Medicare payment. Based on this information, 
we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we 
decided that the Plan does not have to pay for home health services (99601) provided December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary interim partial denture (D5820) provided on 
June 28, 2021. 
 
You asked the Plan to pay for the maxillary interim partial denture. You say that the partial you received is to 
replace your lost tooth. You also say that the partial makes eating and chewing more successful. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental 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 the 
maxillary interim partial denture (D5820) provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on April 2, 2021. 
 
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 the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 2, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion provided on June 9, 2021. 
 
You asked the Plan to pay for the home infusion. You say that the nursing visit notes are attached for review 
and the claim should be reconsidered for payment. The Plan denied your request. The Plan says the billed code 
is not valid for Medicare purposes. 
 
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 99601 is home infusion/specialty drug administration, per 
visit (up to 2 hours). 
 
 
  We find that CPT code 99601 is not supported in the medical record. Specifically, CPT code 99601 has a status 
indicator of I. This means that CPT code 99601 is not valid for Medicare billing purposes. Based on this 
information, we decided that Medicare rules for coverage of the home infusion have not been met. Therefore, 
we decided that the Plan does not have to pay for the home infusion provided on June 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care billed to the enrollee for December 10, 2020.
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 Medicare billing criteria are not met. Maximus overturned the Plans denial for
insufficient information submitted. The Plan requested a reopen and provided additional information. The Plan
says that this denied because the provider has billed this service inappropriately. The provider failed to bill the
correct PDPM/HIPPS Code. The case file includes the appealed claim image that shows the provider has billed
KDPC1, but we found they needed to bill KAPC for payment consideration.
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 codes. In this case, there was an
issue paying this claim as billed due to the submission of an inappropriate code. Medicare rules for coverage
of these services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care
billed to the enrollee for December 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.
You asked the Plan to pre-approve Retacrit. You say that this drug is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Retacrit (Epoetin
alfa-EPBX). The Maximus Physician Reviewer determined that the enrollee is a 76-year-old woman with iron
deficiency anemia and chronic kidney disease stage 4. The enrollee has chronic kidney disease, stage 4 and is
not yet on dialysis. The hemoglobin is 9.5. The enrollee is receiving iron. The elements of the Food and Drug
Administration indication are satisfied. The Plan has requested a reopen and states the Medicare Local
Coverage Determination (LCD) L36276, under limitations states prior to and during ESA therapy for CKD
patients, the patient's iron stores, including transferrin saturation and serum ferritin, should be evaluated.
Transferrin saturation should be at least 20%, and ferritin should be at least 100 mg/mL. The plan argues that
the denial should be upheld, as the enrollee's ferritin was 71 (< 100), and TSAT was 11 (< 20).
Our Medical Director has concluded that the Plan is correct in this case. The medical records show the enrollee
is a 76-year-old woman with Iron deficiency anemia, unspecified. On March 4, 2021 it is documented that the
enrollee's work-up was unrevealing. The notes state "iron saturation 11/ferritin 11." The documentation does
not support that the coverage criteria were met in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 
87798 provided on April 12, 2021. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
payable. 
 
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 find that CPT code 87798 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage 
of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided that the 
Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87798 provided on 
April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis testing provided on May 
6, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this test was ordered by the enrollee's treating 
physician to help determine the course of treatment. The Plan denied your request. The Plan says this test is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81455 will be denied automatically as not 
medically necessary.  
 
We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we 
decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for targeted genomic sequence analysis testing provided on May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received on 
December 18, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not 
understand why you were first charged as an outpatient and then it changed to inpatient. The Plan denied your 
request. The Plan says you were charged this copayment correctly. The Plan says that you were initially billed 
as an outpatient incorrectly.  However, the records confirmed that you were admitted as an inpatient and the 
facility has now corrected the bill.  That is why you were originally assessed outpatient cost sharing, but that 
has been corrected to assess inpatient cost sharing. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per admission for inpatient hospital services.  
 
You have been asked to pay a $295 copayment per admission for the inpatient hospital services. You were 
admitted to the hospital as an inpatient. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital services you received on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 31, 
2021, to June 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you have re-applied for in-
network status and have been denied. You say under traditional Medicare, these claims would not be denied. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 31, 2021, 
to June 9, 2021, by an out-of-network (OON) provider.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do 
not require the necessary services on an inpatient basis, in a skilled nursing facility 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for stereotactic body radiation therapy (SBRT) coded as 77263, 
77470, 77334. 
 
You asked the Plan to pay for stereotactic therapy. You say that Please review the attached medical records in 
lieu or authorization and reconsider claim for payment. The service was medically necessary for the enrollee to 
have done as medical records support. The Plan denied your request. The Plan says the records do not support 
medical necessity. 
 
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 pay for stereotactic therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the submitted medical records have a limited history and physical bout the enrollee. There is not much information regarding the history of the patient outside of the current medical diagnosis. 
Also, the medical records fail to discuss the risk to normal tissue, disease recurrence, and the advantages of 
SBRT over the use of other traditional methods as listed in the criteria for the LCD. The review has determined 
that given the documentation provided for review, SBRT is not medically necessary and reasonable at this 
time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stereotactic therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for stereotactic body radiation therapy (SBRT) coded as 77263, 77470, 77334.
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 enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a long-term acute care hospital (LTACH). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemical cauterization of granulation tissue services 
coded 17250 provided on May 6, 2021. 
 
You asked the Plan to pay for the chemical cauterization of granulation tissue services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
payable.  
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 17250 is chemical cauterization of granulation tissue (ie, 
proud flesh). 
 
We find that CPT code 17250 is not supported in the medical record. Specifically, a total of five units were 
billed of this service for this date of service. The Medically Unlikely Edits (MUE) for this code is four. Review 
of the claim shows that four units of this code were processed and paid by the Plan. Additional units are not 
allowable. Based on this information, we decided that Medicare rules for coverage of the chemical 
cauterization of granulation tissue services have not been met. Therefore, we decided that the Plan does not 
have to pay for the chemical cauterization of granulation tissue services coded 17250 provided on May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services you 
received from May 7, 2021, to May 9, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you should have 
never been admitted to this hospital because you were asymptomatic.  You stated that you should not have to 
pay this coinsurance due to their error. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15% 
coinsurance for inpatient hospital care.  
 
 You have been asked to pay 15% coinsurance for the inpatient hospital services. This coinsurance applies 
regardless of the reason for the inpatient services or your satisfaction with the care you received. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the inpatient hospital services you received from May 7, 2021, to 
May 9, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on May 11, 
2021. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says despite multiple attempts, records were not received to show how the enrollee came to 
the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the SelectMDx test is considered investigational. 
 
Despite multiple attempts, medical records were not received in this case to review for medical necessity. In 
any case, the testing at issue in this case is considered investigational and not covered. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. 
The Plan denied your request. The Plan says pneumatic compression devices for the prevention of deep venous 
thrombosis are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).