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

 
We decided that the Plan does not have to pay for the genetic testing provided on February 27, 2022 billed with 
codes 81206, 81235, 81301, 81162, 81292, 81295, 81298, 81317, 81321, 81402, 81194, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 27, 2022 billed with codes 81206, 81235, 81301, 81162, 81292, 81295, 81298, 81317, 81321, 81402, 
81194, and 81309.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 1, 2021, to 
January 30, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare requires that the services billed be supported 
by documentation that justifies payment. 
 
We looked at the file and Medicare rules. The file shows that the billed services are not adequately supported 
by the submitted documentation. 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 home health 
services rendered from January 1, 2021, to January 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature (L5973). 
 
You asked the Plan to pre-approve an ankle foot system. You say that the features of a K-3 functional level 
MPF will provide the minimum specifications necessary for the enrollee to safely resume his activities of daily 
living. The Plan denied your request. The Plan says the requested device does not meet Medicare criteria as 
reasonable and 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 an ankle foot system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented physiologic change requiring a new prosthetic foot; no 
irreparable change to the foot is documented; no documentation of repairs or needs for the current foot. 
Furthermore, a review of the kinnex foot indicates that this foot has features which exceed the enrollee's 
medical and functional needs such as allowing user to program up to 100 shoes. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ankle foot system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an endoskeletal ankle foot system, microprocessor-controlled feature (L5973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on February 16, 
2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this was not billed with an appropriate modifier. 
 
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 00812 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; screening colonoscopy." 
 We find that CPT code 00812 is not supported in the medical record. Specifically, this code was billed with PT 
modifier. This modifier is only appropriate for CPT 00811. 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 anesthesia services provided to the enrollee on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes 
(81455) provided May 19, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the letter and the attached documents support 
the medical necessity of the tests requested. The Plan denied your request. The Plan says does not meet 
NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Plan, after outreach to the referring provider listed on the claim 
form, was advised that they did not write the order for genetic testing for the enrollee. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater 
genes (81455) provided May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Quad cane. 
 
You asked the Plan to pre-approve a Quad cane. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that canes (E0100, E0105) and crutches (E0110, E0111, 
E0112, E0113, E0114, E0116) are covered if specific criteria are met. 
 
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 Quad cane. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is inadequate documentation that the quad cane at issue in this case meets all of Medicare's LCD criteria 
for medically reasonable and necessary for you. Provided records do not clearly document that you have a 
mobility limitation that significantly impairs your ability to participate in one or more mobility-related 
activities of daily living (MRADL) in the home such as toileting, feeding, dressing, grooming, and bathing 
performed in customary locations in the home. Records do not document a mobility limitation that prevents 
you from accomplishing the MRADL entirely, or, places you at reasonably determined heightened risk of 
morbidity or mortality secondary to the attempts to perform an MRADL; or, prevents you from completing the 
MRADL within a reasonable time frame. Records do not document that you are able to safely use the quad 
cane and the functional mobility deficit can be sufficiently resolved by use of the quad cane as required by the 
LCD. 
 
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 Quad cane have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Quad cane.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient hospital admission and services. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee does not feel safe 
going home and is waiting on discharge to a skilled nursing facility. The Plan denied your request. The Plan 
says that an inpatient admission 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department and/or observation care) would span two 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 been met. Therefore, we decided that the Plan 
has to pre-approve an acute inpatient hospital admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has neither daily skilled nursing nor daily skilled therapy needs. 
 
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 pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and moderate sedation billed to the enrollee for November 8, 2021, under codes 99153, 45385 and G0500 against the original claim.
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 overturned the Plans denial for a lack of complete information in the case file. The Plan requested a reopen and provided additional information. The Plan states codes 45385 and G0500 were denied as no records were received as of November 25, 2021. Records have since been received and procedure codes have been routed to the correct team for a second review. That documentation was provided with the reopen request.
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 and provide records to support the services billed. Code 99153 is not supported in the medical record. Specifically, this code is a technical component only code. The claim shows this service was rendered in a facility setting. Payment for code 99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Codes 45385 and G0500 are being reviewed a second time at the Plan level, therefore we do not have jurisdiction over payment for those codes at this time. Therefore, we decided that the Plan does not have to pay for physician services and moderate sedation billed to the enrollee for November 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provide to the enrollee on August 18, 2021, and billed under code 97710.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says The Plan says that the Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states code 97110 represents a therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The medical records indicate that this service was performed by a qualified physical therapist assistant in the home health or hospice setting. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code G0157 that should be used to bill for the service provided. It is noted that multiple attempts were made to contact the provider for additional information.
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 use of an inappropriate code. 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 physical therapy services provide to the enrollee on August 18, 2021, and billed under code 97710.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee for May 26, 2021,
and billed on November 20, 2021.
You asked the Plan to pay this claim. You say that these services should be coverage by the Plan. The Plan
denied your request. The Plan says this claim is a duplicate of two previously paid claims. Maximus overturned
the Plans denial for medically necessary. The Plan requested a reopen and stated that the issue was not medical
necessity but the fact that the service was previously billed and paid.
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 duplicates of another claim or claim line are denied. The Plan provided
evidence to show these services were previously billed and paid. Based on this information, we decided that the
Medicare rules for this claim have not been met. Therefore, we decided that the Plan does not have to pay for
imaging services provided to the enrollee for May 26, 2021, and billed on November 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay this claim as billed.
You asked the Plan to for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says this claim cannot be paid as billed. Maximus partially overturned the Plans denial for a lack of information in the case file. The Plan requested a reopen and provided clarification on the codes being handled separately. The Plan states that due to new records received from the provider, codes 44140, 44120, and 99223-57 are being reviewed a second time under the Plans reopen process.
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. Code 49255 is a Column 2 code in relation to code 44140. No modifier is allowed to bypass this edit. As such, this was correctly denied. Also, the Plan has provided documentation to show codes 44140, 44120 and 99223 are currently under review for the second time under the Plans reopen process. Therefore, we decided that the Plan does not have to pay for to pay for the medical services provided on October 21, 2021, billed with codes 44140, 44120, 49255, and 99223-57.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 16, 2021,
and billed under codes G0453, 95938, 95957, 95909, 95886, and 95887.
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 denial for codes 95938, 95957, 95909, 95886, and 95887 will be handled separately.
The Plan states code 95937 was approved, and code G0453 does not have the required modifier. Maximus
overturned the Plans denial for insufficient in formation in the case file. The Plan requested a reopen and
provided additional information showing the reprocessing of the additional codes.
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 we find code
G0453 cannot be paid as billed due to the omission of the required modifier. The Plan has provided
documentation with the reopen request to show codes 95938, 95957, 95909, 95886, and 95887 are being
reviewed a second time at the Plan level and code 95937 was paid. Therefore, we decided that the Plan does
not have to pay this claim as billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2022 billed with 
codes 81194, 81301, 81455, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 5, 2022 billed with codes 81194, 81301, 81455, and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the recent hospitalization and office visit 
documentation for further details of the need for the requested device. You say that they have had a recent 
arterial blood gas drawn that shows pressure of carbon dioxide (PC02) of qualifying level for the need for 
device usage. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
intelligent volume-assured pressure support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by 
bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the medical records provided 
show that the enrollee has chronic respiratory failure consequent to COPD. The home ventilator being 
requested is for use in intelligent volume assured pressure support (IVAPS) mode with auto-titration which 
could be provided by a BiPAP device with AVAPS and a back-up rate. This means that the requested ventilator 
is not reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.