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

We decided that the Plan does not have to pre-approve a replacement Kenevo microprocessor knee and prosthetic foot for the enrollee.
You asked the Plan to pre-approve a replacement Kenevo microprocessor knee and prosthetic foot. You say that you disagree with the denial. The Plan denied your request.
The Plan says that the services are not medically necessary. Maximus overturned the Plan's denial based on prosthetist records. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that a determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. The record from the physician fails to show the enrollee is K3 functional ambulator. The need for a power wheelchair demonstrates the enrollee is not a K3 ambulator. Therefore, we decided that the Plan does not have to pre-approve a replacement Kenevo microprocessor knee and prosthetic foot for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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, for 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 September 2, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the enrollee's care needs can be provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has complex functional impairments and active 
medical issues, therefore the enrollee would be expected to require continued inpatient hospitalization with an 
interdisciplinary approach to rehabilitation with close medical supervision. The evaluating therapists 
recommend intensive therapy in an IRF 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that medical records were for submitted for review. The 
Plan denied your request. The Plan says that the enrollee does not need an intensive team for care, medically 
necessary care may be provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that patient has complex functional impairments (critical illness 
myopathy with neurologic weakness is IRF compliant) and active medical issues (thrombocytopenia, 
respiratory failure). Thus, the patient would be expected to require continued inpatient hospitalization with a 
multidisciplinary approach to rehabilitation with close medical monitoring. Additionally, the evaluating 
therapists both recommend continued intensive therapy. The criteria is met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement and negative pressure wound therapy 
provided to the enrollee on May 13, 2022. 
 
You asked the Plan to pay for the services. You say that the attached medical records support the services. 
 The Plan denied your request. The Plan says the services rendered were processed and denied correctly. 
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that in 
this case, the record indicates that the enrollee has a lower extremity wound from the removal infected 
orthopedic hardware placed in the remote past. The record does not indicate the presence of an enumerated 
condition with documentation demonstrating a lack of improvement despite standard wound therapy, including 
the application of dressings, debridement of necrotic tissue (if present), maintenance of an adequate nutritional 
status, and weekly evaluations with documentation of wound measurements (i.e., length, width, and 
depth). The elements of the coverage criteria for negative pressure wound therapy are not satisfied. 
 
Additionally, CPT code 11011 requires debridement including removal of foreign material at the site of an 
open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, 
and muscle. The record provided does not indicate the presence of an open fracture open dislocation. The 
elements of the coverage criteria for CPT code 11011 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for wound debridement and negative pressure wound therapy provided to the enrollee on May 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 12, 2022.
You asked the Plan to pay for this testing. You say that this testing was medically necessary. 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 provided additional information. The Plan noted that this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. However, the specimen was collected during a hospital outpatient encounter, not by the independent lab. In addition, the test has not been cleared or approved by the Food and Drug Association (FDA) and is not a companion diagnostic for any therapy.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was submitted with the incorrect POS code. The documentation provided does not confirm the validity of the testing provided. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on September 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. 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, for 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 (G0482) provided on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided to the enrollee on February 15, 2022.
You asked the Plan to pay for the F1CDx test. You say that this test is a medically necessary covered benefit. The Plan denied your request. The Plan says that the specimen was collected during a hospital outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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 code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided to the enrollee on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on August 19, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately 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 J3490 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of code 64483 that was billed for the same date of service. Based on this information, 
we decided that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code J3490 provided on August 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthesis to include an advanced foot with ankle feature for the enrollee.
You asked the Plan to provide coverage for an advanced foot with ankle feature. You say that at the time of the appeal, the requested advanced foot with ankle feature was medically necessary for the enrollee.
The Plan denied your request. The Plan says the records are inconsistent to show the enrollee qualified as a level K3 ambulator at the time of the appeal. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria the requested advanced foot and ankle feature. Those criteria must be met at the time of appeal. The medical records show at the time of the appeal the enrollee was using a walker or even sometimes a wheelchair for mobility. Whether or not the enrollee had the desire to have the potential to be a K3 ambulator at the time of the appeal does not meet the criteria required for coverage. Medicare rules for coverage of an advanced foot with ankle feature have not been met. Therefore, we decided that the Plan does not have to provide coverage for a prosthesis to include an advanced foot with ankle feature for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $35 copayments charged for psychological telehealth services provided on May 17, 2022, and May 19, 2022.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated the Maximus did not apply the correct contract criteria.
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 $35 copayment for each in person or telehealth specialist visit. The provider billed you for psychological services, which are considered specialist services. 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 $35 copayments charged for psychological telehealth services provided on May 17, 2022, and May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (0239U) provided to the enrollee on February 7, 2022.
You asked the Plan to pay for the laboratory testing. You say that this service was medically necessary and is supported in the medical record. The Plan denied your request. The Plan says that this service was medically necessary and is supported in the medical record.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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 code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing (0239U) provided to the enrollee on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an extraction (D7210) provided on February 21, 2022.
You asked the Plan to pay for these dental services. You say that these dental services should be paid by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overtured the Plans denial for a lack paid benefit information in the file. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. The Plan pays a maximum dental benefit of $250 for the contract year. The Plan provided records to show two claims previously paid exhausted this benefit. The dates of service paid were January 27, 2022, and March 24, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an extraction (D7210) provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine culture services (code 87086) billed for date of 
service August 11, 2022. 
 
You asked the Plan to pay for code 87086. You say that this testing was necessary to determine the appropriate 
treatment for the patient. The Plan denied your request. The Plan says you did not bill this service with a 
covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that that urine culture services are coverable when 
billed with a covered diagnosis code.  You billed the urine culture service in dispute with diagnosis code 
N13.39. Diagnosis code N13.39 in not listed in the controlling Medicare policy as a covered diagnosis for this 
service. Based on this information, we decided that Medicare rules for coverage of code 87086 have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine culture services (code 87086) billed 
for date of service August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services billed with code 74174 for April 15, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services billed with code 74174 for April 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for F5 (coagulation factor V) genetic screening (81241) 
provided on September 1, 2022. 
 
You asked the Plan to pay for F5 genetic screening. You say that you would like to know if any other diagnosis 
code would allow this test to be approved. The Plan denied your request. The Plan says the primary diagnosis 
submitted on this claim, family history of diseases of the blood and blood-forming organs and certain disorders 
involving the immune mechanism (Z83.2) does not support the necessity of this service. 
 
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. The test at issue in this appeal, F5 genetic screening, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for F5 (coagulation factor V) genetic screening (81241) provided on September 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 27, 2022 to 
March 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 27, 2022 to 
March 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service February 7, 
2022. 
 
You asked the Plan to pay for procedure code 93355. The Plan denied your request. The Plan says payment for 
code 93355 is bundled into payment for code 00560. 
 
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 93355 
is a column II code to column I code 00560 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93355 billed for date of service February 7, 2022.