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

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested spinal cord stimulator. 
 
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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for the requested spinal cord stimulator. Our physician reviewer 
found the request is not medically necessary because she has not reached maximum medication therapy. There 
is no documentation of recent physical therapy. There is no adequate documentation of any form of 
neurosurgical evaluation that indicates that she is not a surgical candidate. The request is not medically 
reasonable or necessary at this time. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 31500. 
 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 99232 
is a column II code to column I code 31500. 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 99232 billed for date of service March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673) provided on 
January 20, 2022. 
 
 
 You asked the Plan to pay for a pneumatic compression device. You say that you do not agree with the denial 
for place of treatment and are asking the Plan to reconsider because the segmental gradient pressure pneumatic 
appliance was provided to the enrollee in an ambulatory surgical center and removed before discharge. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare when the 
place of service is an ambulatory surgical center. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a pneumatic compression device have not been met. Specifically, this claim was billed with a POS 
code in an ambulatory surgical center, therefore, it is not a covered benefit. Therefore, we decided that the Plan 
does not have to pay for a pneumatic compression device (E0673) provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214) provided April 6, 2022 to April 
27, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the provider at issue does not accept 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 physician services (99214) provided 
April 6, 2022 to April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
drug testing. We found no exception that would require the Plan to pay for the drug testing. The records 
provided for review do not show that the drug testing was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on January 11, 2022, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on February 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan.. The Plan did not pre-approve the 
ultrasound. We found no exception that would require the Plan to pay for the ultrasound. The records provided 
for review do not show that the ultrasound was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the ultrasound provided on February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2022, to February 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 is billed for each 24-hour period the 
enrollee is provided with implanted pump pain management infusion. You say that S9328 is payable, and the 
claims should be reprocessed for payment. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes. 
  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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2022, to February 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department and related services (87426, 
99283) provided on December 25, 2021. 
 
You asked the Plan to pay for the emergency department and related services. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not 
been billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 87426 and 99283 both are not eligible 
codes for the CS modifier to be billed as they are not on the coinsurance waiver eligible list. Medicare rules 
that the whole claim will be rejected and returned to the provider until the error is corrected. 
 
We looked at the file and Medicare rules. In this case, you have billed codes 87426 and 99283 with the CS 
modifier. These codes are not on the coinsurance waiver eligible list. The required disposition for a claim with 
this edit is Return To Provider. This means the whole claim is returned to the provider. The provider can 
resubmit the claim once the problem is corrected. Based on this information, we decided that Medicare rules 
for coverage of the emergency department and related services have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department and related services (87426, 99283) provided on 
December 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner lift chair (E1399). 
 
You asked the Plan to pre-approve a recliner lift chair. You say that you need the requested lift chair because 
you are not able to get out of your recliner chair and most of the time you are on your back. You also say that 
you have back problems, rheumatoid arthritis and multiple level degenerative disc disease. The Plan denied 
your request. The Plan says the requested lift chair is not covered because it is not medical in nature and is 
regularly and primarily used by persons who do not have a specific medical need for them. 
 
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 recliner lift chair (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on February 1, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test provides actionable results to facilitate 
the detection of recurrent bladder cancer. The Plan denied your request. The Plan says the guidelines for 
bladder cancer shared no commonality with the CxBladder test. 
 
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 pay for the testing services. Our physician reviewer 
found that the enrollee has recurrent superficial bladder cancer. A cystoscopy, ureteroscopy, possible biopsy 
and upper tract imaging will still be necessary regardless of the results of CxBladder testing. Urinary biomarker 
tests such as CxBladder give significant false-negative results in those with urothelial cancer and are subject to 
false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. Therefore, the CxBladder 
test provided would not impact the clinical management of the enrollee and was 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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder testing provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional IMRT fractions for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is needed for the treatment of the enrollee's 
metastatic prostate carcinoma. The Plan denied your request. The Plan says that there is no published evidence 
or trials or guidelines to support 20 fractions of radiotherapy for bone metastasis palliation. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The delivery of 
greater than10 fractions of radiation in the metastatic setting seems outside of the standard of care based on 
NCCN guidelines, ASTRO Choosing Wisely or any consensus guidelines or systematic review. The case file 
does not document the need for going outside of the standard of care with respect to number of fractions of treatment, particularly when using IMRT which would allow more normal tissues sparing than what would be 
achieved with 2D or 3D conformal radiation. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve 10 additional IMRT fractions for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on August 9, 2021, to 
August 10, 2021. 
 
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 procedure code 99291 is 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered on August 9, 2021, to August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures were stolen, and you need 
new ones to eat properly. 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 Plans coverage rules apply in this case. 
 
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 September 25, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and 
complete denture - mandibular (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 6, 2021, through July 
9, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that the enrollee presented with acute 
respiratory failure with hypoxia and sepsis related to community acquired pneumonia. You say that this 
admission was medically necessary, and a favorable outcome should be issued. The Plan denied your request. 
The Plan says principal diagnosis code A41 is not supported. 
 
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 with principal diagnosis code A41.9, defined sepsis, unspecified. 
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 inpatient services at DRG 871. Our reviewer 
says that the documentation does not support principal diagnosis code A41.9. Our physician reviewer found 
that clinical validation criteria was not supported in the medical records.  
 
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 services provided from July 6, 2021, through July 9, 2021, at DRG 871.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fillings (D2391, D2331) provided on April 20, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that the provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for fillings (D2391, D2331) provided on April 20, 2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for this claim as billed due to a billing error.
You asked the Plan to pay this claim. You say this service should be covered by the Plan. The Plan denied
your request. The Plan says Medicare billing criteria were not met. Maximus appeared to have overturned the
appeal, however used the improper letter type to convey its decision. The Plan requested a corrected letter.
Upon review of the case again, the case was reopened.
After review of the claim in the original case file, we find the Plans administrative denial to be correct. The
Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers
must report services with the appropriate codes, modifiers and in this case an identifier, based on the Medicare
LCD guidelines appliable to the service. Medicare requires claims for this type of testing to be billed with a
unique test identifier. Based on L35160, this requirement is applicable as the claim shows the lab test was
rendered in a specific state. The LCD indicates all tests billed within this jurisdiction are required to be billed with a
"Unique Test Identifier." We find do not find this identifier was billed on the claim. The Plan states a corrected
claim would be reviewed if submitted. Therefore, we decided that the Plan does not have to pay for
Hematology Profile Plus and GTC Solid Tumor Plus Profile tests provided July 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance transport provided on September 5, 2021.
You asked the Plan to pay for this claim as billed. You say that this transport should be covered by the Plan.
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. The Plan requested a reopen and provided additional
information. The Plan shows that this claim denied because the procedure code is inconsistent with the
modifier billed. According to our review, the provider has inappropriately billed this service with Modifier RH
- to show the patient is transported from their residence to the hospital. We found the provider needed to bill
with a Modifier QN or QM with the zip code. The case file includes the appealed claim that shows the provider
has inappropriately billed with Modifier RH.
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
cannot be paid as billed due to the omission of an appropriate modifier. Medicare rules for coverage of this
claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for ambulance
transport provided on September 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional pathology services billed for March 10, 2021. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the services. The 
Plan denied your request. The Plan says additional units could not be located. 
 
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 88341 is immunohistochemistry or 
immunocytochemistry, per specimen; initial single antibody stain procedure. The records show that 12 units of 
CPT code 88341 were billed and paid for by the Plan. We find that 3 additional units of CPT code 88341 are 
not supported in the medical record. The medical records do not show that 3 additional units were provided. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the additional pathology services billed for March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code U0003 billed for date of service January 9, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the service should be reimbursed. The Plan 
denied your request. The Plan says there are no circumstances where both procedures of the code pair should 
be paid. 
 
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 U0004 is a column II code to column I code U0003 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 U0003 
billed for date of service January 9, 2022.