Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for radiation therapy related to a clinical trial for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that this treatment should be approved by the Plan. The Plan denied your request. The Plan says services and costs for clinical trials are approved and paid for by Original Medicare. 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. Medicare rules say that Original Medicare covers the approval and costs of services provided in a clinical trial. The records show the enrollee is enrolled in a clinical trial titled: Radiation Therapy in Treating Patients with Stage 0-II Breast Cancer. The trial code is: NCT01245712. This trial meets the Medicare and NIH definitions of a clinical trial.
Requests for treatment and routine cost associated with a Medicare approved clinical trial is covered by original Medicare and not the health plan. Therefore, we decided that the Plan does not have to provide coverage for radiation therapy related to a clinical trial for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing provided to the enrollee on January 20, 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 reported Dex-Z code is not correct. Maximus overturned the Plans denial stating Local Coverage Article A58481 shows Dex Z-code ZB863 can be reported with code 81595. The Plan requested a reopen and stated they believed this was incorrect.
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, Local Coverage Article, A58481 is not in the MAC B coverage jurisdiction and therefore cannot be applied to this service. This means the Dex-Z code reported is not correct. Medicare rules for coverage of these services have not been met as billed. Therefore, we decided that the Plan does not have to pay for lab testing provided to the enrollee on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services billed under Claim A.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided additional information. The Plan demonstrated that Claim A is a duplicate to a claim (Claim B) previously paid to this provider for the same services on same date of service.
The Plan is correct in this case. 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. There is no evidence presented to support that the billed services were provided twice on the same date. The Plan has provided documentation to show these services were previously paid under Claim B on July 31, 2022. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 21, 2021, and billed under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a POV. 
 
You asked the Plan to pre-approve a POV. You say that a POV is medically necessary. The Plan denied your 
request. The Plan says that the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 POV. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that there is insufficient clinical 
documentation regarding the enrollees function, including level of mobility and ability to perform daily 
activities, and physical examination findings, including motor strength and range of motion. There is a lack of 
documentation indicating that the enrollee cannot use a cane, walker, or manual wheelchair for their mobility  needs and it is not clear if they can safely use the requested power mobility device. A power mobility 
assessment has also not been performed. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a POV.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic and core buildup services (D6245, D2950) provided 
on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 pontic 
and core buildup services (D6245, D2950) provided on November 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for an 
LTACH admission, and you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve the acute inpatient hospital level of care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met. Our physician reviewer 
found that the enrollee has spinal stenosis and is approved for an elective lumbar decompression. The 
procedure is not on the Medicare inpatient-only list. There is no documentation to support that the enrollee will 
require at least two midnights of inpatient hospital care for the planned procedure. The acute inpatient 
admission is not reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient hospital level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313),
expandable controller (E2377) and calf pads (K0108) for the enrollee.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan
denied your request. The Plan says that the upper limb strength and function are adequate for the enrollee to be
able to control the power options using their own switches which are included in the allowance of these power
options.
Our Medical director looked at the case file and the reopen request. At issue is coverage for an electronic
connection, harness, and expandable controller. Our Medical Director states that the clinical documentation
does not support that there was medical need to control the power options through a joystick. The
documentation is insufficient to demonstrate that the power wheelchair accessories at issue in this case were
medically reasonable and necessary for the enrollee. Our physician reviewer found that the enrollee's condition
does not meet criteria for coverage of an electronic connection, harness, and expandable controller.
We looked at this physician's review, the file, and Medicare rules. Calf pads are not separately payable as they
are included with the base wheelchair package. Based on this information, we decided that Medicare rules for
coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve an
electronic connection (E2311), harness (E2313), expandable controller (E2377) and calf pads (K0108) for the
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a right 
total 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 pay for 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 total 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 pay for acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, above knee or hip 
disarticulation, knee extension assist (L5850), an addition, endoskeletal system, above knee, knee 
disarticulation or hip disarticulation, manual lock (L5925) and an all endoskeletal lower extremity prosthesis, 
axial rotation unit, with or without adjustability (L5984). 
 
You asked the Plan to pre-approve additional prosthetics. You say that you need a new C-Leg due to the 
mother board failing on your current one that is over six years old. The Plan denied your request. The Plan says 
a prosthesis and accessory parts that meets, but does not exceed, your need, can be provided. Some of the codes 
used for the requested knee do not match the items requested. The records do not show why the requested 
advanced rotational unit is needed. The requested items do not meet the coverage criteria. 
 
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 additional prosthetics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are very active and have had four previous prosthetics. You have done well with 
your current prosthesis although it needs replacement. The requested leg has additional features in the knee not 
present in your current leg. The plan is replacing your current leg which has done well for you. The additional 
features L5850 and L5825 are not part of your current leg and the rationale for medical necessity of those 
additions is not provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional prosthetics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist (L5850), an addition, endoskeletal system, above knee, knee disarticulation or hip 
disarticulation, manual lock (L5925) and an all endoskeletal lower extremity prosthesis, axial rotation unit, 
with or without adjustability (L5984).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 10, 2022, to 
May 13, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
appealing the partial recoupment. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient hospital services with 
the incorrect DRG. 
 
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.   
 
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 sepsis. 
The review has determined the documentation did not support code A41.9.  
 
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 May 10, 2022, to May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on June 14, 2021 and billed under code 99239.
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 while code 99233 was paid, the medical records do not support code 99239. Maximus overturned code 99239 as medical records were not submitted with the case file. The Plan requested a reopen and provided the required medical records.
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. The discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to report code 99239. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on June 14, 2021 and billed under codes 99239.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 25, 2022 and billed under code 80307.
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 insufficient information in the case file. The Plan requested a reopen and provided additional claim information. The Plan demonstrated that per NCCI Chapter 10, Section E for Drug Testing, beginning January 1, 2017, presumptive drug testing may be reported with codes 80305-80307. These codes differ based on the level of complexity of the testing methodology. Only one code from this code range may be reported per date of service. Also, beginning January 1, 2016, definitive drug testing may be reported with codes G0480-G0483. These codes differ based on the number of drug classes including metabolites tested. On January 1, 2017, HCPCS code 00659 defining a different type of definitive drug testing was added. Only one code from this group of codes may be reported per date of service. Providers performing validity testing on urine specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed.
A review of the claim system shows that the claim submitted for date of service May 25, 2022, was billed with code 80305, which is a presumptive drug testing code. Based on the Medicare guidelines, only one code from code range 80305-80307 may be reported per date of service. Therefore, the denial for code 80307 was appropriate as it is also a presumptive drug testing code within the code range 80305-80307.
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 could not be paid as billed due to an error with the codes billed. 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 May 25, 2022 and billed under code 80307.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network office visit provided on June 15, 2022.
You asked the Plan to pay for these services. You say that you had prior authorization for this visit. The Plan denied your request. The Plan says there is no prior authorization requested for this visit. Maximus overturned the Plans denial for insufficient medical records. The Plan requested a reopen and provided documentation to show medical records had been requested but were not submitted by the provider.
The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. Therefore, we decided that the Plan does not have to pay for an out of network office visit provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that a CGM is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for a CGM 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 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.