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

 
We decided that the Plan does not have to pay for an emergency department visit (code 99285) and an 
electrocardiogram (code 93010) provided on August 15, 2022. 
 
You asked the Plan to pay for the emergency department visit and electrocardiogram. 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 services at issue were reimbursed 
by the Plan on September 21, 2022. Comparison of the two claims shows these are exact duplicates. There is 
no evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the emergency department visit and electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit 
(code 99285) and an electrocardiogram (code 93010) provided on August 15, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), bone graft 
at the time of implant placement (D6104), and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve surgical placement of implant body (D6010), bone graft at the time of 
implant placement (D6104), and therapeutic parenteral drugs (D9612). You say that you are in pain, and you 
need this surgery as soon as possible. The Plan denied your request. The Plan says there is no coverage for the 
services requested. 
 
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 pre-approve 
surgical placement of implant body (D6010), bone graft at the time of implant placement (D6104), and 
therapeutic parenteral drugs (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options for the enrollee.
You asked the Plan to pre-approve a Group 3 PWC with multiple power options. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the services are not medically necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a Group 3 PWC with multiple power options. Our Medical Director states that the clinical documentation does not sufficiently support that the coverage criteria for a Group 3 power wheelchair with multiple power options were met in this case. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a Group 3 PWC with multiple power options. 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 Group 3 PWC with multiple power options have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission was 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 skilled nursing facility (SNF) coverage. The Maximus Physician Reviewer determined that the requested SNF care was considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found per the most physical therapy notes you had a decline in function just two weeks after hospital discharge in setting of COVID-19. The Plan requested a reopen and states you were not discharged from the hospital 2 weeks prior. You were hospitalized 2 months prior to a rehospitalization on November 18, 2022, after spending nearly two months in a SNF from September 13, 2022, to November 4, 2022. Additionally, the appeal letter submitted to Maximus notes that your function at the time of discharge from the SNF was worse than your function in the hospital. The medical records show you have multiple medical problems including spontaneous abdominal wall hematoma in the setting of warfarin coagulopathy, as well as acute blood loss anemia, acute on chronic renal failure which returned to baseline, and an open right distal tibia and fibula fracture. The Plan is correct in this case. It is documented that you met her nursing and therapy goals. Your condition was stable, and you no longer required skilled nursing services daily. Daily skilled therapy had been completed. Medicare coverage criteria were not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 9, 2022.
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 overtured the Plans denial stating the services were medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the POS code of 81 reported was not correct. The Plan notes that this code is only used when the specimen was taken by the lab. The medical records show the specimen was taken during an outpatient visit and sent to the lab.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim could not be paid as billed due to an error with the POS code reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
right shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The 
Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 
2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a right shoulder arthroplasty. The record does 
not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided 
October 4, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have attached the medical records 
as references to process the claim. The Plan denied your request. The Plan says the information submitted does 
not support this level of service. There is no documented contact with the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy 
services (90832) provided October 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator implant (64555) for the enrollee.
You asked the Plan to pre-approve a neurostimulator implant. You say that the neurostimulator is medically
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a neurostimulator
implant. Our Medical Director states that currently there is insufficient evidence supporting the use of
peripheral nerve stimulation for chronic shoulder pain from degenerative arthritis. The case file does not
contain documentation that selective nerve blocks that would be appropriate for the management of the
enrollee's shoulder pain. It has not been demonstrated that a selected peripheral nerve (axillary nerve,
suprascapular nerve, and/or lateral pectoral nerve, e.g.) has been identified as the source of the enrollee's
shoulder pain. The case file does not contain documentation that axillary nerve, suprascapular nerve, and/or
lateral pectoral nerve blocks have been performed and provided significant pain relief.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a
neurostimulator implant.
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 neurostimulator implant have not been met. Therefore, we decided that the
Plan does not have to pre-approve a neurostimulator implant (64555) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (tens) device 
(E0730) provided on August 28, 2022. 
 
You asked the Plan to pay for a tens device. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says documentation submitted did not 
include proof of delivery or a delivery ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 The record does not contain a valid proof of delivery or a delivery ticket for the supplies provided in this case. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (tens) 
device (E0730) provided on August 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness has not been demonstrated. 
 
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 requested services. Our physician 
reviewer found that bone marrow aspirate is experimental when used as bone graft material in spine surgery. 
More research is needed to show its efficacy. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 3, 2022.
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 are not met. Maximus overturned the Plans denial. The Plan requested a reopen and confirmed a decision could not be made without clinical records from the provider.
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. There is insufficient information submitted with the claim to determine if Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0384-25 and A9270 billed for date of 
service September 14, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says payment for 
code G0384-25 is bundled into payment for code 90791. 
 
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 G0384-25 is a column II code to column I code 90791. Code G0384 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met.  
 
The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered 
drugs provided in this case, identified by code A9270 are not among the types which are covered by Medicare 
Part B. Therefore, we decided that the Plan does not have to pay for procedure codes G0384-25 and A9270 
billed for date of service September 14, 2022.  
 
Benefits for procedure code A9270 may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on November 8, 2022. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images (D0210). You say that the 
dentist called the Plan and was informed you would have no charge. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
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 
intraoral - complete series of radiographic images (D0210) provided on November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request for a power seat elevation is not a 
covered benefit because they are not primarily 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 power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the laryngoscopy provided on July 12, 
2022. 
 
You asked the Plan to waive the coinsurance for the laryngoscopy. You say that you do not agree with this cost 
share. 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 10% 
coinsurance for Medicare-covered surgery or other services at an ambulatory surgical center.  
 
You have been asked to pay $54.50, which is 20% coinsurance of the allowed amount for the laryngoscopy. 
This item/service falls within the outpatient surgery and other medical services provided at ambulatory surgical centers 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 coinsurance for the laryngoscopy provided on 
July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from March 25, 2021, to 
March 31, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 291. 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 inpatient hospital services at the DRG originally billed. 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, there was no clinical or laboratory evidence of respiratory failure with hypoxia. The review 
has determined that the documentation did not support diagnosis code J96.01. The records more support DRG 
292  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from March 25, 2021, to March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861 and 51785 billed for date of service 
July 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the benefit of intraoperative monitoring 
outweighs the costs. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 95861 is needle electromyography; 2 extremities with or 
without related paraspinal areas. The definition of code 51785 is needle electromyography studies (EMG) of 
anal or urethral sphincter, any technique. 
 
We find that CPT codes 95861 and 51785 are not supported in the medical record. The records do not include 
documentation for code 51785. The description included in the documentation does not accurately describe 
code 95861 as billed. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
95861 and 51785 billed for date of service July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and 
pulp vitality tests (D0460) provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the in-network providers rendered needed 
services to alleviate your painful tooth. The Plan denied your request. The Plan says these services are not 
covered by the Plan's dental benefits. 

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 the cone 
beam CT capture and interpretation (D0364) and pulp vitality tests (D0460) provided on November 2, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission was 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.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Based on the medical records provided, you did not require daily skilled nursing or daily skilled services at an inpatient SNF level of care. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.