Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair accessory (E0971) provided September 18, 
2021. 
 
You asked the Plan to pay for the wheelchair accessory. You say that this item was medically necessary. The 
Plan denied your request. The Plan says the record does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a wheelchair accessory (E0971) provided September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator (CPT code(s): L8769 and 
64555). 
 
You asked the Plan to pre-approve the implantable neurostimulator. You say that the device is for the 
enrollees back pain. The Plan denied your request. The Plan says the information your doctor submitted does not support this device as medically necessary. The Plan states the request is not for spinal cord stimulation and 
it is for an auricular stimulator that is placed behind the ear, and Medicare does not cover this type of device. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable 
neurostimulator (CPT code(s): L8769 and 64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the resin-based composite - one 
surface, anterior (D2330), resin-based composite - three surfaces, anterior (D2332) and unspecified preventive 
procedure, by report (D1999) provided May 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the fillings and unspecified preventative procedure. You 
say that you were not informed that the provider is OON. The Plan denied your request. The Plan says the cost-
sharing for the fillings was applied correctly and the unspecified preventative procedure is not a covered 
service. 
 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. The Plan covers the fillings 
with 20% coinsurance of the covered plan allowance after the $100 annual deductible is met. You can get care 
from an OON provider, but you may pay more.  
 
We looked at the file and Medicare rules. You have been asked to pay 20% of the Plans allowed amount for 
the fillings. Additionally, since the fillings were provided OON you are also being asked to pay the difference 
between the Plans allowed amount and the total cost charged by the OON provider. This means you have been 
asked to pay the correct amount based on your contract with the Plan. Though the Plan offers dental benefits in 
excess of Medicare coverage, the unspecified preventative procedure is not among those covered services. 
Therefore, we decided that the Plan does not have to provide additional payment for the resin-based composite 
- one surface, anterior (D2330), resin-based composite - three surfaces, anterior (D2332) and unspecified 
preventive procedure, by report (D1999) provided May 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 23, 
2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare denies coverage when a laboratory assays two or more genes in parallel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on August 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for patient transportation services provided to the enrollee on 
January 8, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee was inpatient at the time the services were rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The enrollee was considered inpatient at the time of service. 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 patient transportation services provided to the enrollee on January 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between 
wheelchair controller and two or more power seating system motors, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), harness for 
upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code 
E2313), power seat elevation system (CPT code E2300) and attendant control, proportional, including all 
related electronics and fixed mounting hardware and (CPT code E2331). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The upgraded electronics (electronic connector to 3 power features) is not medically necessary. They are 
necessary when there is a medical need to control 2 or more power features though the joystick. The notes do 
not show a medical need to control the power features through the joystick. The power features can be 
controlled using their own switches. These switches can be made any size without asking for a separate request. 
They can be made from any material without asking for a separate request. All of this can be done without the 
need to use the joystick to control the power features. The seat elevator is statutorily not covered as it does not 
serve a primary medical purpose, and the attendant control is not covered as the enrollee has been approved for 
a joystick, which is a self-operated drive-control system. Therefore, we decided that the Plan does not have to 
pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided 
at initial issue (CPT code E2377), electronic connection between wheelchair controller and two or more power 
seating system motors, including all related electronics, indicator feature, mechanical function selection switch, 
and fixed mounting hardware (CPT code E2311), harness for upgrade to expandable controller, including all 
fasteners, connectors and mounting hardware (CPT code E2313), power seat elevation system (CPT code 
E2300) and attendant control, proportional, including all related electronics and fixed mounting hardware and 
(CPT code E2331).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 29, 
2022. 
 You asked the Plan to pay for procedure code 70496. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service January 29, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on November 8, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the services billed. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed  
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing provided on November 8, 2018.  
 
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: Favorable

 
We decided that the Plan has to pay for the drug testing provided on November 5, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation does not support the 
service billed. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for the drug testing provided on November 5, 2018.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography services billed to the enrollee under
code 70450 for November 8, 2021.
You asked the Plan to pay for this claim as billed. You say that this service should be covered by the Plan. The
Plan denied your request. The Plan says this service was paid on a previous claim. Maximus overturned the
Plans denial for a lack of documentation in the case file showing previous payment. The Plan requested a
reopen and provided the required documentation of payment. The Plan says that a National Correct Coding
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 70450 and 70496. This PTP edit has
a modifier indicator of 1, meaning modifiers associated with NCCI are allowed, however, an appropriate NCCI
modifier was not billed with this PTP code edit on the claim.
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
cannot be paid as billed due to the omission of a required modifier. Medicare rules for coverage of this claim as
billed have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography
services billed to the enrollee under code 70450 for November 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services.
You asked the Plan to cover SNF services. At the time of the appeal, you stated that SNF services were
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for SNF services
were not met. Maximus overturned the Plans denial stating SNF services would be beneficial. The Plan
requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. 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.
Based on the medical records provided, you did not require daily skilled nursing or daily skilled therapy
services at an inpatient level of care. Based on the medical records, you care needs were custodial and social in
nature and did not meet the required coverage criteria for admission to a SNF. Therefore, we decided that the
Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency services visit on September 
06, 2021. 
 
You asked the Plan to waive the copayment for emergency services. You say that You should not have to pay a 
$90 emergency services copay, because the visit was a result of improper care you received there a month 
earlier. The Plan denied your request. The Plan says this is a covered service and has a copay per visit. 
 
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 $90 
copay for emergency services.  
 
You have been asked to pay $90 copay for emergency services. Emergency services falls within the emergency 
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 an emergency services visit on September 06, 
2021.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by urgent care on 
February 27, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to urgent care with 
symptoms of Pneumonia. They sent you home with irritation as a diagnosis. You went to your PCP the next 
day and you were diagnosed with pneumonia after diagnostic tests were performed. The Plan denied your 
request. The Plan says For urgently needed services, you pay $50 for each Medicare-covered 
urgent care facility visits. This copayment is not waived if you are admitted as an inpatient to the hospital 
within 24 hours for the same condition. 
 
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 urgently needed services.  
 
 
 
 You have been asked to pay $50 copayment for urgent care visit. Urgent care visit falls within the urgently 
needed 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 an office visit provided by 
urgent care on February 27, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus 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: Favorable

 
We decided that the Plan has to pay for the drug testing provided on September 19, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service billed. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for the drug testing provided on September 19, 2017.  
 
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.