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

 
We decided that the Plan does not have to pay for the services (36465) provided on April 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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. 
 
In this case, the CPT Code Manual definition of code 36465 is "Injection of non-compounded foam sclerosant 
with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance 
and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous 
vein)". 
 
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 code 36465 is 
not supported by the records provided. Our reviewer found that the records do not include enough information 
to confirm this procedure has been performed. In this procedure, the provider injects a non-compounded foam 
sclerosing solution into a single incompetent truncal vein of the extremity under ultrasound guidance to guide the dispersion of foam, most commonly to treat a varicose vein. This code is used for a single truncal vein of 
the extremity. Detail of this procedure was not found in medical record. 
 
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 (36465) provided on April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that you are requesting reconsideration for the 
denial of a PET/CT scan. The Plan denied your request. The Plan says the PET/CT scan requested is not 
medically necessary. 
 
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/CT scan. Our reviewer says 
that the PET scan is not medically necessary at this time. Our physician reviewer found the last PET scan was 
performed on September 9, 2022 revealing no evidence of recurrent metastatic disease. A repeat PET scan was 
requested however, as the last PET scan did not show evidence of worsening, a repeat PET scan is not justified 
as it is not expected that it would worsen. There was no report of new symptoms or new evidence to support 
this repeat PET scan. 
 
 
 
 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/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve a SPECT study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Myocardial Perfusion Imaging will be considered 
medically reasonable and necessary for specific indications.  
 
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 a SPECT study. Our reviewer says that 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
this enrollees clinical management. Our physician reviewer found the rationale for the test is not clear, as the 
enrollee is reported as having no chest pains or other cardiovascular symptoms. There is no documentation that 
the electrocardiogram shows an uninterpretable pattern or that the enrollee is unable to exercise. There is no 
evidence provided that would support the need for radionuclide stress testing 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 a SPECT study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 16, 2022.
You asked the Plan to pay for this testing.  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. The Plan requested a reopen and stated that the claim did not include the required unique test identifier or Dex-Z code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Review of the remarks section of the claim shows the unique testing identifier code was not reported. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this will not improve your dementia so your rehab can be provided at a lower level of 
care such as LTACH. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal cancer screening 
 
You asked the Plan to pay for the screening services. You say that you are requesting coverage for the test 
completed in October 2022, since the test completed February 2022 was actually for the physical in September 
of 2021. The Plan denied your request. The Plan says the maximum benefit visit limit has been exceeded. 
 
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.  
Though the Plan offices a colorectal cancer screening benefit, certain limitations apply. The records show your 
benefit for the requested service was exhausted on February 6, 2022. This service is a covered benefit, but the 
benefit visit limit has been exceeded. Therefore, we decided that the Plan does not have to pay for the 
colorectal cancer screening
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve microsatellite instability analysis (81301) and PIK3CA gene analysis (81309) for the enrollee.
You asked the Plan to pre-approve these services. You say that this testing is medically necessary. The Plan denied your request. The Plan says that your records show that your cancer was diagnosed above age 70 and you do not meet the revised Bethesda Lynch Syndrome (LS) guidelines.
Our Medical director looked at the case file and the reopen request. At issue is coverage for microsatellite instability analysis (81301) and PIK3CA gene analysis (81309). Our Medical Director states that MSI testing is required by the FDA for the clinical use of Keytruda (Pembrolizumab) in patients who have unresectable or metastatic solid tumors who have progressed following prior treatment and have no satisfactory alternative options. The documentation does not support this scenario in the enrollee. PIK3C is an individual Tier 2 genetic test that is unlikely to impact therapeutic decision-making, directly impact treatment, outcome, and/or clinical management, and is denied as not medically necessary. Our physician reviewer found that the enrollee's condition did not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve microsatellite instability analysis (81301) and PIK3CA gene analysis (81309) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99356 provided on January 8, 2022. 
 
You asked the Plan to pay for procedure code 99356. You say that the medical records support the billing of 
code 99356. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99356. 
 
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 99356 is Prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for 
inpatient or observation Evaluation and Management service). 
 
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 procedure code 99356. Our reviewer says that the medical 
records do not support the billing of code 99356. Our reviewer found to bill 99356, you need to spend at least 
55 minutes face-to-face with that patient on that day. That includes the 25 minutes for the level 2 subsequent 
visit plus at least 30 additional minutes. In this case, the medical record does support prolonged service as the time for primary evaluation and management is not documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99356 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99356 provided on January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0463 billed for date of service July 5, 2022, 
to July 26, 2022. 
 
You asked the Plan to pay for procedure code G0463. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code G0463 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code G0463 is statutorily excluded from Medicare payment. Based on this information, we decided that Medicare rules for coverage of procedure code G0463 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code G0463 billed for date of service July 5, 2022, to July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for gene analysis services provided to the enrollee on November 22, 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 Medicare billing criteria were not met. Maximus overturned for insufficient information regarding the denial. The Plan requested a reopen and provided additional information. The Plan noted that the provider has billed six different procedure codes for the comprehensive cardiovascular NGS panel. This is incorrect as the provider shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. The Medicare billing guidelines, NCCI Chapter X Pathology / Laboratory Services (codes 80000 - 89999) section "F. Molecular Pathology" stated if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory must report only one unit of service. If no code accurately describes the procedure performed, the laboratory may report code 81479 (Unlisted molecular pathology procedure) with one unit of service. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the enrollee where the results will directly affect management of the specific medical problem.
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, this claim was not billed with the appropriate code for the service provided. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for gene analysis services provided to the enrollee on November 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 more home physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the enrollee's level of function no longer requires the 
intervention of skilled therapists. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning 
at a level commiserate with a lower level of care (i.e., home exercise program, outpatient therapy, layperson 
supervision). As such, the requested, ongoing, home health physical therapy services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 more home physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for date of service October 23, 
2022. 
 
You asked the Plan to pay for procedure code A4595. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid 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 procedure code. 
 
We find that procedure code A4595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4595 is statutorily excluded from Medicare payment. Based on this information, we decided that Medicare rules for coverage of procedure code A4595 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4595 billed for date of service October 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $250 copayment charged for magnetic resonance imaging (MRI) of the breast provided on August 2, 2022.
You asked the Plan to waive this cost share. You say that you are at high risk and all screening services provided to you of this type should be covered. The Plan denied your request. The Plan says while the diagnostic MRI was covered by the Plan, this type of service requires cost share. Maximus overturned the Plans denial stating mammography screenings are covered. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria to the correct service.
The Plan is correct in this case. 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 $250 copayment for outpatient diagnostic services such as an MRI.
This was billed as a diagnostic MRI by your provider. The Plan paid its share of this service as is required by your Plan contract, based on the claim submitted by your provider. 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 $250 copayment charged for magnetic resonance imaging (MRI) of the breast provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an endoskeletal ankle foot system, microprocessor-controlled 
feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve an ankle foot system. You say that the molded distal cushion is indicated to 
maximize residual limb skin integrity. The enrollee underwent a surgical operation last fall because of an 
ongoing wound over his fibular head despite several months of wound care therapy. To avoid future surgical 
intervention and potential complications, the molded distal cushion is indicated as this will further lesson the 
forces translating to his residual limb and provide an added protective interface. The Plan denied your request. 
The Plan says that while the enrollee's physician documents that the enrollee has K3 potential, the notes do not 
give any medical reason why he requires a microprocessor foot. No medical reason is given why a mechanical 
K3 foot will not meet the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an ankle foot system. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is working in maintenance which requires a variety of positions and active work. 
The microprocessor does provide more stability and is associated with reduced falls. The enrollee has an active 
occupation and would benefit from the more advanced system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ankle foot system have been met. Therefore, we decided that the Plan has to 
pre-approve an endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar 
flexion control, includes power source (L5973).  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on July 12, 2022, coded as D2740
for a porcelain ceramic crown.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan The Plan
denied your request. The Plan says you were not enrolled in the supplemental dental benefit that allows
coverage of this service. Maximus overturned the Plans denial. The Plan requested a reopen and provided
confirmation that you were not eligible for this service at the time it was rendered.
The Plan is correct in this case. Medicare generally does not cover dental services. The Plan follows the same
rule. The services you are asking the Plan to pay for were covered under a supplemental dental benefit you
were not a member of at the time of service. Therefore, we decided that the Plan does not have to pay for
dental services provided on July 12, 2022, coded as D2740 for a porcelain ceramic crown.