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

We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 3, 2021, billed under codes 29823-RT and 29825-RT.
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 while a portion of this claim was paid, the Medicare billing criteria were not met for codes 29823 and 29825. Maximus overturned the Plans denial bases on the medical necessary. The Plan requested a reopen and stated medical necessity was not the issue, but that the codes billed were reported in error. The Plan states that codes 29827-RT, 29826-RT, 29828-RT, 29823-RT, 29824-RT and 29825-RT were billed. The Plan states codes 29827-RT, 29826-RT, 29828-RT and 29824-RT were approved. The Plan states that code 29823-RT was not supported in the records provided and code 29825-RT is included in the payment of another code.
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, we confirmed code 29823-RT is not supported in the records provided describing surgical shoulder arthroscopy. Code 29825 is included in the payment of code 29827. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee and billed under codes 29823-RT and 29825-RT on December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have a medical condition where 
you need the incontinence garments 24/7. The Plan denied your request. The Plan says the requested items is 
not covered by your plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization (GAE). 
 
You asked the Plan to pre-approve GAE services. You say that the requested procedure is medically necessary. 
You say that the requested procedure is less invasive. You say that the enrollee has tried steroid and non-steroid 
procedures and is walking with a cane. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for coverage of the requested procedure. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic embolization is covered for certain 
medical 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 GAE services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee was being treated for 
unilateral primary osteoarthritis of the left knee. She presented with pain in the left knee for years, and pain that 
has increased in the last 3-4 months. The exam reveals reduced sensation on the inside of the left lower leg. There is tenderness to palpation of the medial and lateral joint lines and around the patella. There is a bony 
overgrowth observed. There is pain with Lachmans. There is a mildly reduced range of motion. This condition 
is not amendable to this treatment. There is limited published, large-scale, long-term peer-reviewed literature 
that shows geniculate artery embolization to be an effective and/or safe treatment for the noted osteoarthritic 
pathology. The studies, as noted above, state geniculate artery embolization is a safe and effective tool for the 
management of recurrent hemarthrosis of the knee following arthroplasty. In this case, she has not had a total 
knee arthroplasty and is requesting this procedure to delay a total knee. However, there is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GAE services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve geniculate artery embolization (GAE).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services for the enrollee, 11 total visits, to be provided from April 30, 2022, through June 27, 2022.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria required for a new session of home health care. Maximus overturned the Plans denial for a lack of notice of non-coverage. The Plan requested a reopen and stated this was not for continued care but for a new home health visit series of visits.
The Plan is correct in this case. 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. Based on the medical records provided, the enrollees needs did not require skilled services personnel. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services for the enrollee, 11 total visits, to be provided from April 30, 2022, through June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
does not have problems that need 24-hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient services from October 8, 2022, forward were requested. 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 continued services.  Our physician reviewer found that it was not expected this enrollee would improve in a reasonable period of 
time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations. He was without aggressive behaviors while not showing any acute threats of safety. The 
enrollee reported feeling safe in the hospital setting and was worried about his safety out the community. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal 
thoughts, auditory or visual hallucinations or abnormal behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 17, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services performed by the non-participating provider 
were not authorized by the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
September 17, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88112, 88305, 88312, 88361) provided on 
November 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 88112, 88305, 88312, & 88361 is not supported in the medical record. Specifically, this 
service has a professional component / technical component indicator of 1. The service was performed in the 
outpatient hospital setting. The professional interpretation of a diagnostic test must be separately billed with 
modifier 26 by the interpreting physician. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (88112, 88305, 88312, 88361) provided on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 4, 2021 billed with 
codes 81194, 81317, 81321, 81298, 81292, 81295, 81301,81309, 81311, 81235, 81275, 81210, 81276, & 
81206. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory 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. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 4, 2021 billed with codes 81194, 81317, 81321, 81298, 81292, 81295, 81301,81309, 81311, 81235, 
81275, 81210, 81276, & 81206.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Part B drugs and outpatient diagnostic on 
April 13, 2022. 
 
You asked the Plan to waive the cost sharing for Part B drugs and outpatient diagnostic. You say that you want 
to appeal the amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered Part B drug. Covered drugs include drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. You must pay a $275 copayment for each Medicare-covered diagnostic 
service. Covered services include but are not limited to diagnostic Imaging (CT scan, MRI/MRA, Myocardial 
Nuclear Perfusion Imaging and PET scans). The provider billed in the amount of $20 and the allowed amount 
is $12. $12 x 20% = $2.40. $2.40 + $275 = $277.40. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and a $275 copayment for outpatient 
diagnostic. This item/service falls within the Medicare Part B prescription drugs 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 cost sharing for Part B drugs and outpatient diagnostic on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on May 20, 2022, by an OON provider. 
 
You asked the Plan to pay for a drug test. You say that you are an independent laboratory and you don't 
actually see the patients. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a drug test provided on May 20, 2022, by an OON 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician is contracted with 
the Plan and the testing was necessary to treat the enrollee. The Plan denied your request. The Plan says that 
the rendering and referring providers are both OON providers and there was no approved authorization. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there remains a dearth of randomized, blinded clinical studies examining the long-term 
clinical outcomes to establish the value of CardioMEMS in patient management. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99334) provided on February 23, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the rest home visit (99334) provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on February 16, 2022. 
 
You asked the Plan to pay for annual wellness visit. You say that you were not aware that the annual wellness 
visit is covered every 12 months and thought it is covered once every calendar year. The Plan denied your 
request. The Plan says you received a covered annual wellness visit on January 6, 2022; therefore, 12 months 
had not passed before this annual wellness visit was performed. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and
pelvis (74176) provided on September 14, 2021.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says this is a duplicate claim. Maximus overturned the Plans denial for a lack of
information in the case file regarding the paid claim. The Plan requested a reopen and provided additional
information. The Plan states that the submitted documentation supports 1 (one) unit of 74176-26, which was
previously approved and paid. Medicare billing guidelines states services must be verified in the submitted
physician documentation. There is no additional documentation supporting an additional study.
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, the Plan has
provided documentation to show this claim was previously paid. Therefore, we decided that the Plan does not
have to pay for the computed tomography (CT) scan of the abdomen and pelvis (74176) provided on
September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies (K0553 and K0554). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the enrollee has severe life-threatening 
hypoglycemic episodes unrelated to diabetes or diabetic treatment. The Plan denied your request. The Plan says 
the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The enrollee's records do not show that they have diabetes, that they 
have a treatment plan that requires insulin injections or an insulin pump, or that a treatment plan is frequently 
adjusted based on results of glucose testing. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CGM and supplies (K0553 and K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect testing (0012M) provided on March 21, 
2022. 
 
You asked the Plan to pay for CxBladder Detect testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for Current 
Procedural Terminology (CPT) codes 0012M and 0013M for CxBladder.  
 
We looked at the file and Medicare rules. The requested service is listed as non-covered by Medicare. Based on 
this information, we decided that Medicare rules for coverage of CxBladder Detect testing have not been met. 
Therefore, we decided that the Plan does not have to pay for CxBladder Detect testing (0012M) provided on 
March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 3, 2021.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim was denied due to a lack of medical record documentation to show the service was provided and how the enrollee came to or was referred to the provider. The Plan states several requests were made for these records however they went unanswered.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine coverage.
Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 3, 2021.