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

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds (12011) provided on 
October 29, 2021. 
  You asked the Plan to pay for the simple repair of superficial wounds (12011). You say that the codes are 
appropriately identified as separate services and the claim should be processed for payment. The Plan denied 
your request. The Plan says an appropriate modifier was not billed with this code edit. 
 
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 12011 
is a column II code to column I code 21310. 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 the simple repair of superficial wounds (12011) provided on 
October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from October 28, 2021, to November 1, 2021. 
 You asked the Plan to pay for the self-administered drugs. You say that the self-administered medications were 
provided to the enrollee by the staff. You also say that you do not understand why you are being charged. The 
Plan denied your request. The Plan says the claim was processed correctly. 
 
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 pay for the self-administered drugs 
provided in an outpatient setting from October 28, 2021, to November 1, 2021.  
 
Benefits for the self-administered drugs 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: Partially Favorable

 
We decided that the Plan has to pre-approve the services. We decided that the Plan does not have to pre-
approve MRI of the spine.  
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan says that it 
is not evident that the enrollee required an initial evaluation of suspicious mass/tumor of the bones, muscles or 
soft tissues of the pelvis found on an imaging study, and needing clarification, or found by physical exam and 
remains non-diagnostic after x-ray or ultrasound. 
 
We decided that the Plan has to pre-approve MRI of the pelvis.  
 
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 for MRI of the pelvis. Our reviewer says that this 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the has tenderness to 
palpation of her coccyx without radiating pain or back pain. Investigation of the coccyx via MRI of the pelvis 
makes sense as she is extremely uncomfortable. Physical therapy is not necessary to establish the need for MRI 
of the pelvis. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve MRI of the pelvis.  
 
We also decided that the Plan does not have to pre-approve MRI of the spine. 
 
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 for MRI of the spine. Our reviewer says that this MRI 
is not medically reasonable or necessary. Our physician reviewer found that it is noted that the coccyx is not 
included in the field of view of MRI of the lumbar spine. Although she has had lumbar surgery in the past there 
are no symptoms indicating injury or other process in the lumbar spine. There is no radiating pain or reflex 
abnormality. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the spine have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MRI of the spine. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the 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 the lab services 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 lab services 
provided on July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right reverse total shoulder joint replacement surgery 
(23472). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee's condition is not remotely 
consistent with impingement syndrome as she has clear evidence of severe glenohumeral joint arthritis and a 
reverse total should arthroplasty is the appropriate treatment option at this time. The Plan denied your request. 
The Plan says the requested procedure is does not meet the medically necessary criteria. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show that the enrollee is a smoker and smoking is a contraindication to 
shoulder replacement surgery as it causes wound healing problems. There is no documentation of smoking 
cessation for at least 6 weeks. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve right reverse total shoulder joint replacement surgery (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on November 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that the treatment is part of a comprehensive pain 
management program. The Plan denied your request. The Plan says the code is a non-covered 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, the CPT Code Manual definition of code 62320 is Injection(s), of diagnostic or therapeutic 
substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 
substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; 
without imaging guidance. 
 
We looked at the file and the rules. We find that CPT code 62320 is not supported. Injections performed 
without image guidance are not considered reasonable and necessary. The billed code is also not a covered 
code. Based on this information, we decided that Medicare rules for coverage of the services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for the injection services provided on 
November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of drug-eluting implant, including punctal 
dilation when performed, into lacrimal canaliculus. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful for treatment of the 
health problem. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee will be undergoing bilateral cataract surgery.  The record 
notes normal lacrimal drainage and does not provide an indication or the requested service. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of drug-eluting implant, including punctal dilation when performed, into lacrimal 
canaliculus.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT codes 99291 and 93010. We decided that the Plan does not have 
to pay for CPT code 99053.  
 
You asked the Plan to pay for CPT codes 99291, 93010 and 99053. The Plan says that CPT code 99053 
remains denied as bundled services are not eligible for separate reimbursement. 
 
We decided that the Plan has to pay for CPT codes 99291 and 93010.  
 
The Plan says that you are only appealing CPT code 99053. The records submitted do not support this is the 
only code being requested. The Plan has not forwarded any evidence to support the other codes are not being 
requested or that they were being handled separately. It is the burden of the Health Plan to substantiate their 
decision with evidence. In this case, the decision to not review CPT codes 99291 and 93010 has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for CPT codes 
99291 and 93010.  
 
We also decided that the Plan does not have to pay for CPT code 99053. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of CPT code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 
99053. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Synvisc-One. Our reviewer says that 
the requested use of Synvisc-One is not supported. Our physician reviewer found the requested use of Synvisc-
One is not FDA-approved for your diagnosis. Its use is not supported by one of the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from May 14, 2021, to
May 18, 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 records provided do not support the diagnosis codes billed. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
Our Medical Director looked at the case file and the reopen request. At issue whether the medical records
support the inpatient services billed.
Maximus determined that the plan did not make reasonable and diligent efforts to gather and forward
information regarding their decision. The Plan requested a reopen and argues that the diagnosis of A41.9
(Sepsis, Unspecified Organism) cannot be validated. The Plan states that the diagnosis of J69.0 (Pneumonitis
due to Inhalation of Food and Vomit) can be validated as the principal diagnosis. The plan notes that the
progress notes do not contain documentation stating a diagnosis of sepsis. The discharge summary notes,
"admitted to medicine for delirium 2/2 aspiration pna" and does not contain documentation stating a diagnosis
of sepsis. The submitted documentation does contain a post-discharge provider clarification note dated May
25th which states "sepsis due to pneumonia, present on admission." However, a post discharge query was not
submitted for our review. In this case, a diagnosis of sepsis is not stated clearly or consistently throughout the
medical record nor is there a complete query submitted for our review. "Therefore, the diagnosis of A41.9
(Sepsis, Unspecified Organism) cannot be validated."
The medical records show that the enrollee was an 85-year-old woman with a history of diabetes, hypertension,
and a sacral ulcer, who was bedbound. The was admitted to the hospital on May 14, 2021, with pneumonia of
the right lung. Vital signs were notable for diastolic hypotension. Laboratory studies were notable for
leukocytosis, renal insufficiency, an elevated lactate, and an elevated troponin T. The discharge summary dated
May 18, 2021, documents problems of pneumonia, at risk for dehydration, diabetes, disorientation, and
essential hypertension.
Our Medical Director has determined that the Plan is correct in this case. The available medical documentation
is insufficient to support a principal diagnosis of A41.9 (Sepsis, Unspecified Organism). We looked at this
physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do
not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care
provided to the enrollee from May 14, 2021, to May 18, 2021.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 received oral medications, had stable vital 
signs and your lungs were clear. You were at a supervision/touch assist to moderate assist level for functional 
mobility. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of 
illness or intensity of service criteria for 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory service provided on November 
2, 2021. 
 
You asked the Plan to waive the copayment for laboratory service. You say that this is a covered claim that 
should be paid in full. The Plan denied your request. The Plan says the copayment is correct. 
 
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 $40 
copayment for each in-network, freestanding laboratory visit.  
 
You have been asked to pay $3, which is less than the standard $40 copayment for laboratory services. The 
laboratory service falls within the Laboratory services benefit category. 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 laboratory service provided on November 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for skilled nursing facility (SNF)
services provided from April 8, 2021, to May 4, 2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost share was based on the services provided within the
benefit period and the Plan contract agreement for this type of service. Maximus partially overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language. The
Plan noted that the medical record documentation shows the discharge date was May 4, 2021, and not April 30,
2021. The Plan stated the claim shows code 30, which indicates you were in the SNF during the same benefit
period. Therefore, this cost share was applied correctly.
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 $50 copayment for days 21-100, per benefit period, for SNF care.
Based on the number of days SNF services were provided, 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 or reduce the cost share for
skilled nursing facility (SNF) services provided from April 8, 2021, to May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265) and intravenous sedation (D9239, D9243). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the biologic materials are not a covered service, and the criteria for 
coverage of intravenous sedation are not met. 
 
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, none of these requested items or 
services are among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve biologic materials to aid in soft and osseous tissue regeneration (D4265) and intravenous sedation 
(D9239, D9243).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider did not send in notes for review. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of magnetic resonance imaging (MRI) of 
the spine. have been met. Despite multiple attempts, the provider did not send in any medical records. These 
medical records are needed to determine the medical necessity of this request. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine.