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

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 27, 2021.
You asked the Plan for these services. You say that this claim should be paid. The Plan denied your request.
The Plan says these services must be addressed under the enrollee's Medicaid benefit. Maximus overturned the
Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim
denied under the Medicare benefit because the enrollee is Medicaid eligible. The Plan included documentation
to show that the enrollee is Medicaid eligible. The Plan says that Medicare pays covered dually eligible
beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover
medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and
home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. The contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under the enrollees
Medicaid coverage and not their Medicare coverage. The IRE does not have jurisdiction over Medicaid
benefits. Therefore, we decided that the Plan does not have to pay for these services under the Medicare
benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided to the enrollee on May 5,
2020 and billed under code 92134.
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 this is not an eligible code for use in services provided to skilled nursing facility (SNF)
residents. Maximus overturned the Plans denial. The Plan requested a reopen and provided documentation to
show this code is excluded under Medicare billing for SNF residents.
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 CPT code. In this case, the
Medicare billing guidelines state that code 92134 is not subject to SNF billing. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmology
services provided to the enrollee on May 5, 2020 and billed under code 92134.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitrectomy or face down positioning unit.
You asked the Plan to pay for a vitrectomy or face down positioning unit. You say that your physician
recommended this equipment. The Plan denied your request. The Plan says this equipment was purchased from
a vendor is not a Medicare eligible provider. 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. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a physician or practitioner who has
opted out of the program. Even if your physician recommends a piece of equipment for you, the Plan contract
rules must still be followed. You did not have prior authorization for this equipment. You purchased this
equipment from a vendor who is not a Medicare eligible provider. You did not follow your Plan contract rules
when you obtained this equipment. Therefore, we decided that the Plan does not have to pay for a vitrectomy or
face down positioning unit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81241, 81240, 81291, 81230) 
provided on September 21, 2021. 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. 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 code 81479.Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81241, 81240, 81291, 
81230) provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hip surgery provided to the enrollee on February 17, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file to support the Plans decision. The Plan requested a reopen and provided
additional medical records. The Plan states that the medical records show that procedure code 27006 is
considered inclusive to code 27299 and is not payable as billed.
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, code 27006
cannot be paid as billed due to its bundled relationship with code 27299. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for hip surgery provided
to the enrollee on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper eyelid Blepharoplasty and repair of brow ptosis.
You asked the Plan to pre-approve the upper eyelid Blepharoplasty and repair of brow ptosis. You say that you would like reconsideration because the requested procedures are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.
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 upper eyelid Blepharoplasty and repair of brow ptosis. Our reviewer says that the documentation, including photographs, does not adequately support the medical necessity of the requested procedures. Our physician reviewer found there is insufficient documentation of a functional deficit. 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 upper eyelid Blepharoplasty and repair of brow ptosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the upper eyelid Blepharoplasty and repair of brow ptosis.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for computed tomography services provided July 16, 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 codes 70450 and 70460 cannot be billed together. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that per the National Correct Coding Initiatives (NCCI), a Procedure to
Procedure (PTP) edit exists between 70450 and 70460. This PTP edit has a modifier indicator of 0, which
indicates there are no modifiers that are allowed with this PTP code pair. The Plan also showed code 70460
was paid under claim number a previous claim on September 28, 2021. The Plan states if the CCMI is a "0",
and the provider or supplier coded the claim correctly, there are no circumstances in which both procedures of
the PTP code pair should be paid for the same beneficiary on the same day by the same provider or supplier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services with the appropriate codes. In this case, this claim was billed with an inappropriate modifier.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for computed tomography services provided to the
enrollee on July 16, 2021 and billed under code 70450.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that at the time of the appeal, SNF services were
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The
Maximus Physician Reviewer determined that the enrollee qualified for SNF coverage. The reviewer found that
the enrollee was reportedly functioning below her baseline and had yet reached a plateau in function. A period
of daily skilled therapy was determined to be reasonable to improve the enrollee's strength, train caregivers,
establish a maintenance program, and/or prevent deterioration of the enrollee's condition. The Plan requested a
reopen and argued that daily therapy is not reasonable for a broken wrist.
The medical records show the enrollee is a 91-year-old woman with a history of atrial fibrillation and seizures,
who suffered a fracture of her left wrist in a fall on January 25, 2022. It is documented that, due to limited
caregiver support for assistance required at home and home set-up, discharge to post-acute rehab and skilled
OT was recommended. On February 9, 2022, it is documented that the enrollee ambulated 10 feet with a rolling
walker with minimal assistance.
Our Medical Director has determined that the Plan is correct in this case. The documentation does not
demonstrate that it was medically reasonable and necessary to provide skilled therapy services daily, on 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge services provided to the enrollee on May
9, 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 these services were already paid. Maximus overturned the Plans denial because the case
file lacked proof of previous payment. The Plan requested a reopen and provided documentation of previous
payment.
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, the Plan has provided documentation to
show these services were paid on June 30, 2021. Therefore, we decided that the Plan does not have to pay for
hospital discharge services provided to the enrollee on May 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on November 5, 2019.

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 due to the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare. Maximus overturned the Plans denial for lack of documentation to show the enrollees hospice status on the date of service. The Plan requested a reopen and provided the required documentation.

The Plan is correct in this case. 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 Plan has provided documentation to show 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 medical services provided to the enrollee on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a partial denture.
You asked the Plan to provide coverage for a partial denture. You say that a partial denture is necessary. The
Plan denied your request. The Plan says this benefit was provided in 2018 and is only covered every five years.
Maximus overturned the Plans denial. The Plan requested a reopen and provided documentation to show this
benefit was provided in 2018. Therefore, would not be available again until November of 2023.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the partial denture benefit was covered
in 2018 and therefore is not available again until 2023. Therefore, we decided that the Plan does not have to
provide coverage for a partial denture.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted miscellaneous procedure (78999) provided on 
October 30, 2021. 
 
You asked the Plan to pay for the unlisted miscellaneous procedure. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says the 
documentation that was provided fails to show the services 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. 
 
In this case, the CPT Code Manual definition of code 78999 is unlisted miscellaneous procedure, diagnostic 
nuclear medicine. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the unlisted miscellaneous procedure. Our reviewer says that 
the documentation does not support the CPT code as billed. Our reviewer found the documentation does not 
include documentation of an unlisted procedure, and therefore cannot be verified.  When reporting unlisted 
procedure, additional documentation should be reported to support the use of the unlisted procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the unlisted miscellaneous procedure have not been met. Therefore, we decided 
that the Plan does not have to pay for the unlisted miscellaneous procedure (78999) provided on October 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic screening panel provided on July 7, 2021. 
 
You asked the Plan to pay for cardiovascular genetic screening panel. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not 
covered by Medicare. 
 
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 cardiovascular genetic screening panel. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that genetic cardiovascular screening testing does not meet the 
definition of cardiovascular disease screening. The services were not medically reasonable and necessary for 
the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiovascular genetic screening panel have not been met. Therefore, we 
decided that the Plan does not have to pay for cardiovascular genetic screening panel provided on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee is not a candidate for Forteo due to 
arthritis and poor vision. You say that the enrollee lives with her spouse who is disabled and not able to help 
her. You say that it has been over a year since the enrollee has had any treatment. The Plan denied your 
request. The Plan says the enrollee has not tried the preferred drug Forteo. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
age related osteoporosis without osteoporotic fracture.  The requested medication is a new start. The provided 
records indicate that the Plan's alternative drug Forteo is the agent recommended.  The provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided by a participating 
provider on August 11, 2021, to November 11, 2021. 
 
You asked the Plan to pay for an endosteal implant. You say that your tooth was broken, and you had to have it 
extracted. The Plan denied your request. The Plan says D6010 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for an endosteal implant (D6010) provided by a 
participating provider on August 11, 2021, to November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve protective outer surface covering (L5962) and vacuum 
socket (L5781). 
You asked the Plan to pre-approve protective outer surface covering and vacuum socket. You say that these 
extra prosthetic items are medically necessary for the enrollee's condition. The Plan denied your request. The 
Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. 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. 
 
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 protective outer surface covering and 
vacuum socket. Our reviewer says that the requested prosthetic items are not medically reasonable and 
necessary. Our physician reviewer found that the protective outer surface covering system exceeds the patient's 
medical needs and is not medically necessary per Medicare criteria as the documentation does not support that 
the patient requires this protection against unusually harsh environmental situations where it is necessary to 
protect the lower limb prosthesis beyond the level of protection that is afforded by a standard cover. The 
physician documentation does not reveal unusually harsh environmental conditions that cannot be met with a 
standard cover.  
 
Regarding the vacuum socket, the documentation notes the volume management system is an Otto Bock 
Harmony P3.  A review of this socket online indicates that this is an elevated vacuum volume management 
system, L5781 - Addition to lower limb prosthesis, vacuum pump, residual limb volume management and 
moisture evacuation system, exceeds the patient's medical needs and is not proven superior to a standard 
socket. Therefore, it does not meet Medicare medically necessary criteria. Furthermore, the literature reviewed 
indicates that further research is needed with clinical trials that recruit larger sample sizes and report long-term 
outcome data for the requested vacuum suspension system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of protective outer surface covering, and vacuum socket have not been met. 
Therefore, we decided that the Plan does not have to pre-approve protective outer surface covering (L5962) and 
vacuum socket (L5781).