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

We decided that the Plan does not have to pay for shoulder arthroscopy with debridement (29823) and shoulder
arthroscopy with rotator cuff repair (29827) provided to the enrollee on November 24, 2021.
You asked the Plan to pay this claim. of the codes billed. You say that this claim should be paid. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned
the Plans denial for code 29827. The Plan requested a reopen and provided additional information. The Plan
noted that code 29823 is not supported. The operative report did not include documentation of a surgical
shoulder arthroscopy with extensive debridement for 3 or more discrete structures therefore this code cannot be
verified. The Plan states only 2 areas were fully debrided. Per Assistant December 2020: "As with all
other arthroscopic debridement codes, it is important to note that the structures debrided as part of another
procedure reported for the same session cannot be counted to meet the criteria of the debridement code."
Debridement of 3 or more discrete structures where no other work was performed is not documented.
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 code 29823 is
not supported. Another more appropriate code should haven been used instead. Medicare rules for coverage of
any of the codes billed have not been met.
Therefore, we decided that the Plan does not have to pay for shoulder arthroscopy with debridement (29823)
and shoulder arthroscopy with rotator cuff repair (29827) provided to the enrollee on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist telehealth visit on April 12, 2022
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you did not go into
the office and should not be responsible for the copayment. The Plan denied your request. The Plan says this
cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for Medicare-covered telehealth services received from a specialist.
You have been asked to pay a $45 copayment for the specialist telehealth visit. This item/service falls within
the Medicare-covered telehealth services received from a specialist benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the specialist telehealth visit on April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging billed under code 75625-59.
You asked the Plan to pay for this code as billed. You say that this claim should be paid. The Plan denied your
request. The Plan says code 75625-59 is not supported by the medical records submitted. The operative report
did not include documentation of an abdominal aortography by serialography with radiological supervision and
interpretation; therefore, this code cannot be verified. Maximus overturned the Plans denial stating the services
appear to have been provided as documented. The Plan requested a reopen and stated that o cite the operative
report; "Under real-time ultrasound guidance, the other-Proximal right superficial femoral artery was evaluated
and determined patent and an appropriate potential access site. The vessel was then cannulated with concurrent
real-time ultrasound visualization of access with a 21-gauge needle. The vessel was then cannulated with
concurrent real-time ultrasound visualization of access with a 21-gauge needle." There is insufficient
documentation present to sufficiently describe or support the requisite criteria for approval of the requested
code.
The Plan states per the National Correct Coding Initiative Policy Manual for Medicare Services, Revision Date:
1/1/2022; in regard to the submitted (CPT) code of 75625-59, a local anesthetic is applied over the common
femoral artery. The artery is percutaneously punctured with a needle and a guidewire is fed through the artery
into the abdominal aorta. A catheter is threaded over the guidewire to the point of study and the guidewire is
removed. Contrast medium is injected, and films are taken by serialography, producing a series of individual xray
films. This code reports the radiological supervision and interpretation. Use a separately reportable
code for the catheterization. For injection procedures, see 93567, which include imaging interpretation and
report. If the abdominal plus bilateral iliofemoral vessels are studied, see 75630. Contrast media may be
reported with A4641, Q9951, Q9958-Q9967. Procedure 75625 has both a technical and professional
component. To report only the professional component, append modifier 26. To report only the technical
component, append modifier TC. To report the complete procedure (i.e., both the professional and technical
components), submit without a modifier. This description was not documented in the operate report narrative.
Therefore code 75625-59 is not supported in the documentation therefore is not payable.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. The records provided do not sufficiently
demonstrate the billing of code 75625-59 is appropriate. Medicare rules for coverage of this code as billed have
been met. Therefore, we decided that the Plan does not have to pay for imaging billed under code 75625-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on
January 25, 2022.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that the service at issue was maintenance
therapy, which is not eligible for payment per Medicare guidelines.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance
care.
We looked at the file and Medicare rules. The file includes medical records from your physician indicating you
were seen for maintenance/wellness care. Your appeal request to the Plan also states that your physician billed
this as maintenance because you had no issues at the time. 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 chiropractic manipulative treatment (98941) provided on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on June 28, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on June 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for 3D rendering provided to the enrollee on September 21, 2021.
You asked the Plan to pay for 3D rendering provided to the enrollee on September 21, 2021. 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 denial stating the service was medically necessary. The Plan requested a reopen and
stated that the issue was not medical necessity but the lack of required documentation in the case file. The Plan
notes that this is an administrative determination for noncoverage and is not based on clinical criteria for
medical necessity. The use of 3D-rendering with interpretation and reporting of computed tomography,
magnetic resonance imaging, or other tomographic modality with image postprocessing is not covered
separately by Medicare as it is contained in the authorized radiologic procedure. Radiologic techniques using
3D-rendering will be considered integral to the radiology services and not a separate service. In addition, the
appealing provider is not the surgeon, but the radiologist.
There are no radiology records provided. The Plan requested these records several times. Medicare
says, "for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met, and physicians must report
services correctly." Therefore, due to the absence of the required medical documentation, this service
cannot be verified.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. There is insufficient information in the record
to determine if Medicare rules for coverage of 3D rendering were met. Therefore, we decided that the Plan does
not have to pay for 3D rendering provided to the enrollee on September 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has moderate persistent 
asthma. She has not tried and failed the Plan's required drugs, at least three months of maximally-tolerated 
inhaled corticosteroids and/or oral systemic corticosteroids plus a long-acting beta antagonist. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Fasenra 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fasenra.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285), and implantable event recorder (C1764). 
 
You asked the Plan to pre-approve the insertion of a implantable event recorder. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the insertion of a implantable event recorder have not been met. Specifically, there is no record of 
stroke or syncope. Therefore, we decided that the Plan does not have to pre-approve the insertion, subcutaneous 
cardiac rhythm monitor, including programming (33285), and implantable event recorder (C1764).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Epidural Steroid Injections (62323). 
 
You asked the Plan to pre-approve the Epidural Steroid Injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat Epidural Steroid Injections when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using the same scale for at 
least three months. 
 
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 Epidural Steroid Injections. Our 
reviewer says that the requested injections are medically necessary. Our physician reviewer found physician 
notes document that the enrollee had 50% pain relief for 3 months after each prior injection. Coverage criteria 
for repeat injections is met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Epidural Steroid Injections have been met. Therefore, we decided that the 
Plan has to pre-approve Epidural Steroid Injections (62323).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 23, 2022, to 
February 21, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is a notice of admission on file. The 
Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The claim information shows that the enrollee received home health 
services in 2021 whose services continue in to 2022. The records do not show that a notice of admission with 
an artificial admission date was submitted. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from January 23, 2022, to February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
February 15, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that this service should be covered. The Plan 
denied your request. The Plan says the provider in this case is not eligible to receive Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nursing facility care have not been met. Therefore, we decided that the Plan does not have to 
pay for the subsequent nursing facility care (99309) provided on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MAKOplasty procedure (C1776). 
 
You asked the Plan to pre-approve a MAKOplasty procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 MAKOplasty procedure. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is limited published, large-scale, long-term, peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the enrollee's pathology. The clinical benefits 
(including ultimate outcomes of functional improvement and pain reduction) with computer navigation over standard surgery are not evident in large-scale, long-term, peer-reviewed literature. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 MAKOplasty procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MAKOplasty procedure (C1776).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of lateral exostosis (maxilla or mandible) 
(D7471). 
 
You asked the Plan to pre-approve dental services. You say that you need this service because you are in pain, 
weight loss and having trouble eating. The Plan denied your request. The Plan says this service is not covered 
under your Plan. 
 
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. Removal of lateral exostosis 
(maxilla or mandible) (D7471) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested Removal of lateral 
exostosis (maxilla or mandible) (D7471) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve removal of lateral exostosis (maxilla or mandible) (D7471).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF admission.
Our Medical director looked at the case file and the reopen request. At issue is coverage for SNF care. Our Medical Director states the documentation does not support that the required skilled services continued to be medically reasonable and necessary on a daily basis in an inpatient skilled nursing facility. Our Medical Director found that your condition did not meet Medicare criteria for SNF care. 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 skilled nursing facility (SNF) care.