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

 
We decided that the Plan does not have to pay for a home blood pressure monitor. 
 You asked the Plan to pay for the home blood pressure monitor. You say that this item was medically 
necessary. The Plan denied your request. The Plan says blood pressure monitors are not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pay for a home blood pressure monitor.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care in a facility. 
 
You asked the Plan to pre-approve custodial care. 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 must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve custodial care 
in a facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment, methadone, (G2067) 
provided on July 7, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the provider is able to bill Medicare for 
rendered services as the facility is certified by Substance Abuse and Mental Health Services Administration 
(SAMHSA). The Plan denied your request. The Plan says the billing provider is not eligible to receive payment 
from Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment, 
methadone, (G2067) provided on July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77012 billed for date of service September 
21, 2022. 
 
You asked the Plan to pay for procedure code 77012. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 77012 is bundled into payment for 
code 76942. 
 
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 77012 
is a column II code to column I code 76942. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 77012 billed for date of service September 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided to the enrollee on February 14, 2022.
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by Medicare. The Plan denied your request. The Plan says that the specimen was collected in the hospital.
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 collected in the hospital. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided to the enrollee on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Rollator Comfort Package, provided on March 30, 2022. 
 
You asked the Plan to pay for the Rollator Comfort Package. You say that the items should be covered. The 
Plan denied your request. The Plan says these items are not covered. 
 
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 pay for the Rollator Comfort Package, provided on March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 Power Wheelchair (code K0862) or any of the requested accessories.
You asked the Plan to provide coverage for a Group 3 Power Wheelchair (code K0862) with accessories: E2311, E1028, E2313, E2300, E2625, E0953, E2363, E1012, E2377, E1007, and E0955. You say that at the time the appeal was requested, this equipment was medically necessary. The Plan denied your request. The Plan says the required coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Maximus medical review did not apply the correct criteria. The Plan noted that while they agree the enrollee has a medical need for a power wheelchair, the enrollee does not meet the criteria for the K0862 and multiple power options and accessories.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for the type of Group 3 Power Wheelchair and advanced accessories requested. Based on the medical records provided, there is no documentation of pressure ulcers, history of healed pressure ulcers or healed flap surgery. The enrollee does not perform self-catheterization. There is no indication of spasticity by the neurologist. The enrollee is not on any medications for treatment of a condition or physical limitation which would require the advanced power wheelchair requested and /or the advanced accessories requested. All the listed Medicare criteria for coverage of this equipment were not met at the time of the appeal. Therefore, we decided the Plan does not have to provide coverage for a Group 3 Power Wheelchair (code K0862) with accessories: E2311, E1028, E2313, E2300, E2625, E0953, E2363, E1012, E2377, E1007, and E0955.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the additional skilled nursing visits are 
medically necessary. 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 that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
 
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 six home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76942 and J2001 billed for date of service 
December 7, 2021, to December 21, 2021. 
 
You asked the Plan to pay for procedure codes 76942 and J2001. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 76942 and J2001 is bundled into 
payment for codes 20610 and 20611. 
 
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 codes 
76942 and J2001 are column II codes to column I codes 20610 and 20611. This claim has not been billed with 
an appropriate modifier to bypass the edit. 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 codes 76942 and J2001 billed 
for date of service December 7, 2021, to December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical and physician services billed with codes 99231, 
99221, and 20610 for July 11, 2022, to July 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the diagnosis code was not billed to the highest 
level of specificity. 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 the surgical and physician 
services billed with codes 99231, 99221, and 20610 for July 11, 2022, to July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services received from April 4, 202, to 
August 28, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that these services are covered. The Plan 
denied your request. The Plan says the diagnosis codes billed by the provider are invalid 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the diagnosis codes billed are invalid. The claims are 
not payable as billed. Therefore, we decided that the Plan does not have to pay for the acupuncture services 
received from April 4, 202, to August 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from April 1, 2022, to May 16, 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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for a lack of information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that information submitted in the original file was the incorrect verbiage. The provider submitted the Notice of Admission (NOA) on April 15, 2022, for the home health care period which started on April 1, 2022. According to Medicare guidelines, the deadline for submission of Notice of Admission (NOA) has to be within 5 days of the start of care.
The Notice of Admission (NOA) was not within 5 days after the admission date of April 1, 2022. The provider submitted the Notice of Admission (NOA) on April 15, 2022, for the home health care period which started on April 1, 2022. According to Medicare guidelines, the deadline for submission of the home health claims Notice of Admission (NOA) has to be within 5 days of the start of care. This NOA was not submitted timely.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the NOA was not submitted within the timeframe required by Medicare. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from April 1, 2022, to May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tumor testing (81479) provided to the enrollee on April 26, 2022.
You asked the Plan to pay for the testing. You say that this test was necessary and is supported in the medical record. The Plan denied your request. The Plan says that the specimen was collected during a hospital outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was collected in the hospital. 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 tumor testing (81479) provided to the enrollee on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 Power Wheelchair with upgraded
electronics (E2377, E2311 and E2313) for the enrollee.
You asked the Plan to provide coverage for the upgraded electronics coded as E2377, E2311 and E2313. We
note the Plan approved the requested power wheelchair and Medicare allowed accessories. You say that at the
time of the appeal, the requested power wheelchair and accessories were medically necessary for the enrollee.
The Plan denied your request. The Plan says while the power wheelchair and Medicare allowed accessories
were approved by the Plan, the upgraded electronics exceed the enrollees needs in the home. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct
coverage criteria. The Plan notes that though the member may have significant spasticity with limited range of
motion of the upper limbs with pain, the medical records show the enrollee can operate the individual switches
provided with the approved power wheelchair and the upgraded electronics not only are not necessary but
exceed the enrollees need for equipment used in the home.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare covers power mobility
equipment accessories that are demonstrated to be medically necessary for use in the home.
Based on the medical records provided, the requested upgraded electronics are neither medically necessary nor
are the needed for the enrollee to operate the power wheelchair in the home. Therefore, we decided that the
Plan does not have to provide coverage for a Group 3 Power Wheelchair with upgraded electronics (E2377,
E2311 and E2313) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval 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 documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99337) provided on September 12, 2022. 
 
You asked the Plan to pay for the physician 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. 
 
In this case, the CPT Code Manual definition of code 99337 is Domiciliary or rest home visit for the evaluation 
and management of an established patient. 
 
We find that CPT code 99337 is not supported in the medical record. Specifically, the claim was billed with 
Place of Service 12, Home. This code is not payable for this place of service. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99337) provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74178, G0463, G1004 and Q9967 provided 
to the enrollee on August 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 74178: 
 
Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed 
by contrast material(s) and further sections in one or both body regions 
 
Healthcare Common Procedure Coding System (HCPCS) G0463: 
 Hospital outpatient clinic visit for assessment and management of a patient 
 
HCPCS G1004: 
 
Clinical decision support mechanism national decision support company, as defined by the medicare 
appropriate use criteria program 
 
HCPCS Q9967: 
 
Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that G0463 was not reported with the 
correct bypass modifier when a procedure was performed during the same visit. All other claims processing 
denials are due to the lack of a correct modifier. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 74178, G0463, G1004 and Q9967 provided to the enrollee on August 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (G6002). 
 
You asked the Plan to pre-approve the therapy. You say that the enrollee has a biopsy proven nodular basal cell 
carcinoma on the forehead. The Plan denied your request. The Plan says the requested service 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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for 
daily IGRT for a technology for which need has not been established by published data or supported by 
consensus guidelines (many of which recommend against treatment with these devices in general- citations 
below) is not necessary. Billing for daily IGRT would not be furnished in accordance with accepted standards 
of medical practice." 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image guided radiation therapy (IGRT) (G6002).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 29, 2022, to 
September 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line 
on which the first four positions of the HIPPS code match the code submitted on the RAP. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the proper revenue 
code. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
August 29, 2022, to September 14, 2022.