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

 
We decided that the Plan does not have to pre-approve vertebroplasty/kyphoplasty (22514). 
 
You asked the Plan to pre-approve vertebroplasty/kyphoplasty (22514). You say that the requested 
vertebroplasty/kyphoplasty (22514) is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested vertebroplasty/kyphoplasty (22514). 
 
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 vertebroplasty/kyphoplasty (22514). 
Our reviewer says that the enrollee does not meet criteria for the requested vertebroplasty/kyphoplasty (22514). 
Our physician reviewer found the enrollee was being treated for a wedge compression fracture of fourth lumbar 
vertebrae. He presented with complaints of low back pain. This began two months prior. He has had multiple 
falls in the past. The radiographs were performed and reviewed to reveal a superior endplate compression 
fracture of the L4 vertebral body. The magnetic resonance imaging (MRI) was reviewed and a burst fracture at 
L4 was identified that appeared to be acute. However, the MRI-documented L4 burst fracture is not clearly 
documented to be acute (less than 6 weeks) or subacute (6-12 weeks). The MRI was dated November 7, 2022, 
and on the November 10, 2022, note he was seen on October 28, 2022, with complaints of back pain that began 
2 months prior. Additionally, there is a 3mm degenerative anterolisthesis of L4 on L5 documented on the MRI 
(representing potential instability.) Therefore, the enrollee does not meet the LCD criteria for the requested 
vertebroplasty/kyphoplasty (22514). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty/kyphoplasty (22514). have not been met. Therefore, we decided 
that the Plan does not have to pre-approve vertebroplasty/kyphoplasty (22514).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says procedure code 97010 is considered bundled and 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 procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service May 4, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation services (99152). 
 
You asked the Plan to pre-approve moderate sedation services. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions. 
 
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 moderate sedation services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documentation of unique circumstances of medical necessity. There is no documentation provided that this 
procedure, which can be performed safely without conscious sedation or monitored anesthesia care, cannot be 
done. The review has determined that sedation services are not medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve moderate sedation services (99152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 foot and microprocessor knee

You asked the Plan to pre-approve the services. You say that the enrollee has the ability, potential, and need to ambulate at the K3 functional level. The Plan denied your request. The Plan says this is not medically necessary.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation provided does not support the use of a microprocessor knee and that the patient is a K3 level ambulator. There is insufficient clinical documentation regarding the patient's current level of mobility and function, and it only provides what the patient's potential is versus his current level of mobility. There is no standardized inventory provided regarding the patient's K level. The clinical letter of appeal does not address if the patient's cardiac conditions of peripheral vascular disease and coronary artery disease will allow him to function at a K3 level. Additionally, there is insufficient documentation regarding the patient's motor strength and range of motion in the lower extremities. This information is needed to determine if the requested microprocessor knee is appropriate and necessary.

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 a K3 foot and microprocessor knee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core build up on tooth #31 (D2950).
You asked the Plan to pre-approve a core build up. You say that the provider told you that the core build up needs to be replaced. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted.
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. Maximus overturned the Plan's denial. The Plan sent in documentation to show these services have already been received. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply.
The record shows your benefit for the requested item or service was exhausted on date of service May 25, 2022. Therefore, we decided that the Plan does not have to pre-approve a core build up on tooth #31 (D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says payment for code 0245U is bundled into 
payment for code 0018U. 
 
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 0245U 
is a column II code to column I code 0018U 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 0245U billed for date of service April 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve routine transportation services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested provider is out-of-network with the Plan. The Plan says that they confirmed with your facility, and they have set up transportation with their contracted transportation provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve routine transportation services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 26, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one home health visits. 
 
You asked the Plan to pre-approve one home health services. You say that the requested services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
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. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesn't support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. The requested home health services are not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve one home health visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene panel testing provided on April 8, 2022.
You asked the Plan to pay for the testing services. You say that the documents support medical necessity. The Plan denied your request. The Plan says that the specimen was collected during an 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 gene panel testing provided on April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shock absorber (E1015), hand rim (E2205), and push 
handles (K0108). 
 
You asked the Plan to pre-approve a shock absorber (E1015), hand rim (E2205), and push handles (K0108). 
You say that the requested shock absorber (E1015), hand rim (E2205), and push handles (K0108) are medically 
necessary. The Plan denied your request. The Plan says the requested shock absorber (E1015), hand rim 
(E2205), and push handles (K0108) are not medically necessary. 
 
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 a shock absorber (E1015), hand rim 
(E2205), and push handles (K0108). Our reviewer says that the requested shock absorber (E1015), hand rim 
(E2205), and push handles (K0108) are not medically necessary. Our physician reviewer found the enrollee has paraplegia and limited capacity to use a wheelchair in the community. The accessories are requested for 
community use. Per NCD 280.3 the wheelchair is provided to assist with mobility related activities of daily 
living (MRADLs). The requested accessories are to facilitate community use and are not medically necessary 
to achieve MRADLs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a shock absorber (E1015), hand rim (E2205), and push handles (K0108) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a shock absorber (E1015), hand 
rim (E2205), and push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care coded 99223 provided on June 29, 
2022. 
 
You asked the Plan to pay for the initial hospital care. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs.  Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside 
and on the patient's hospital floor or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the medical records do not 
support a medical decision making of high complexity. Based on this information, we decided that Medicare 
rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not 
have to pay for the initial hospital care coded 99223 provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided to the enrollee on May 3, 2022.
You asked the Plan to pay for the F1CDx testing. You say that this service was medically necessary. The Plan denied your request. The Plan says that the specimen was collected in an outpatient facility.
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 testing (0037U) provided to the enrollee on May 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional PT visits. 
 
You asked the Plan to pre-approve seven additional PT visits. You say that the service should be covered 
because it helps with the pain and to function from day to day. The Plan denied your request. The Plan says 
seven of the additional PT visits are not medically necessary. 

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you are receiving a repetitive exercise program and massage. 
Continued input from a skilled therapist is not medically necessary. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 10, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan. 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 stated that Maximus did not apply the correct billing criteria. The Plan demonstrated that this was an administrative determination for non-coverage and is not based on clinical criteria for medical necessity. The FANCC and BLM genes are not a Medicare benefit and are statutorily excluded service. In addition, the claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office, meaning the independent laboratory took the sample and used a place of service (POS) code of 81. However, the medical records show the specimen was collected in an outpatient facility and not by the billing laboratory.
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, this claim could not be billed due to an error with the POS code and a lack of documentation to show this testing was required for the enrollee or valid at the time of testing. 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 March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder (K0108). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested item is a convenience item and not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cup holder (K0108).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided on September 1, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that there is inadequate documentation provided to 
support the medical necessity for repeat professional visits at a frequency exceeding Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a valid Medicare rule to substantiate the 
denial. Therefore, we decided that the Plan has to pay for subsequent nursing facility care provided on 
September 1, 2022.   
 
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.