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

We decided that the Plan does not have to pay for an office visit billed to the enrollee for April 2, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. You also submitted
medical records directly to the IRE to show these services were rendered and were necessary. The Plan denied
your request. The Plan says payment was denied for a claim submission issue. Maximus overturned the Plans
denial for insufficient information in the case file. The Plan requested a reopen and provided additional
information. The Plan stated this was not a medical necessity denial but a provider identification denial.
The Plan provided documentation to show this claim denied because the provider billed with a taxonomy
identifier that is not certified or eligible for payment under Medicare. The Plan provided documentation from
the NPI website showing the taxonomy code reported is not valid and is not eligible for Medicare payment.
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 the taxonomy
code reported for the provider is not a Medicare eligible taxonomy code. Therefore, we decided that the Plan
does not have to pay for an office visit billed to the enrollee for April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration (D4265), guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) 
(D4267), and bone replacement graft for ridge preservation - per site (D7953) provided November 8, 2021. 
 
You asked the Plan to pay for the biologic materials to aid in soft and osseous tissue regeneration, guided tissue 
regeneration and bone replacement graft. You say that you have already paid a large amount of money and 
need help with the remaining amount. The Plan denied your request. The Plan says these services are note 
covered under your 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 the 
biologic materials to aid in soft and osseous tissue regeneration (D4265), guided tissue regeneration - 
nonresorbable barrier, per site (includes membrane removal) (D4267), and bone replacement graft for ridge 
preservation - per site (D7953) provided November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), prophylaxis - 
adult (D1110), resin-based composite - three surfaces, posterior (D2393), and resin-based composite - three 
surfaces, anterior (D2332) provided November 15, 2021. 
 
You asked the Plan to pay for the panoramic x-ray, dental cleaning and fillings. You say that a claim was 
misfiled for a November 18, 2021, date of service and you were dissatisfied with the services provided. The 
Plan denied your request. The Plan says you have exceeded the frequency limits for these services. 
Additionally, the Plan states the provider has voided the claim for November 18, 2021. 
 
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 Plan covers the panoramic 
x-ray once every five years, two dental cleanings per calendar year and two fillings per calendar year.   
We looked at the file and Medicare rules. The Plan provided documentation that coverage has been provided 
for a complete series of x-rays on April 16, 2019. The Plan has provided coverage for two cleanings and two 
fillings in 2021.Based on this information, we decided that the Plan's frequency limit for coverage of the 
panoramic x-ray, dental cleaning and fillings has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the panoramic radiographic image (D0330), prophylaxis - adult (D1110), resin-based composite 
- three surfaces, posterior (D2393), and resin-based composite - three surfaces, anterior (D2332) provided 
November 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) occupational therapy visits (CPT code 97110 
x4). 
 
You asked the Plan to pre-approve the occupational therapy visits. You say that the services are necessary. The 
Plan denied your request. The Plan says the services are not considered medically necessary. 
 
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 occupational therapy visits. Our 
physician reviewer found the additional requested therapy generally is not accepted as specific and effective 
therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the 
documentation does not reveal that you require the ongoing unique skills of a professional therapist to safely 
and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. You are independent in a home exercise program. The 
requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
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 occupational therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve four (4) occupational therapy visits (CPT code 97110 x4).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 24, 2021, billed with 
code 99053. 
You asked the Plan to pay for the services as billed. You say that you do not feel that the disallowed amount of 
$3,117.11 is appropriate. You say that Texas State law mandates certain payment levels for claims of non-par 
providers. The Plan denied your request. The Plan says this was paid at the Medicare allowable amount. No 
payment was made for 99053 as it is bundled with other billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99053 has a status indicator of "B" in the Medicare Physician Fee Schedule. This means that payment for 
this code is always bundled into payment for other services. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on July 24, 2021, billed with code 99053.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 2, 
2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the services should be covered 
as you disagree with the charges. 
 The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $375 
copayment for Outpatient hospital services.  
 
You have been asked to pay a $375 copayment for a colonoscopy. Colonoscopies fall within the Outpatient 
hospital services 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 a colonoscopy 
provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator (PNS). 
 You asked the Plan to pre-approve an auricular PNS. You say that auricular PNS is medically necessary for this 
patient. The Plan denied your request. The Plan says medical literature does not support the use of this device 
for the patient's condition. 
 
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 auricular PNS. Our reviewer says 
that an auricular PNS is not medically necessary. Our physician reviewer found the patient in this case suppers 
from complex regional pain syndrome (CRPS) type 1 affecting both lower extremities. The doctor found that 
there is no evidence to support the use of this device in the treatment of CRPS.  The request is not medically 
reasonable or 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 an auricular PNS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an auricular peripheral nerve stimulator (PNS).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the breast reconstruction services coded 19364 and billed with the 62 
modifier provided on November 22, 2021. 
 
You asked the Plan to pay for the breast reconstruction services as billed. You say that you would like this 
claim reprocessed based no the medical records. The Plan denied your request. The Plan says that the 
documentation does not support the billing of modifier 62. 
 
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 19364 is breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap). In this case, modifier 
62 indicates 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the breast reconstruction services as billed. Our reviewer 
says that the documentation supports the services as billed. Our reviewer found the record documents that the 
enrollee underwent the noted procedure.  The record contains two operative notes, one by each of the two 
surgeons who performed the enrollee's procedure. The operative reports support the necessity for co-surgeons.  
The operative reports indicate that the surgeons worked simultaneously performing different parts of the 
procedure. The elements of the coverage criteria are satisfied.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the breast reconstruction services as billed have been met. Therefore, we 
decided that the Plan has to pay for the breast reconstruction services coded 19364 and billed with the 62 
modifier provided on November 22, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on October 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that you are an invisible provider and would like 
to be linked to the facility claim if they were paid. The Plan denied your request. The Plan says the hospital 
claim was also denied with the same code. The rendering provider is an out-of-network provider and there was 
no referral from the enrollee's primary care physician or an approved authorization. Also, the service rendered 
was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the imaging services provided on October 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound of the heart. 
 
You asked the Plan to pre-approve an ultrasound of the heart. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 ultrasound of the heart. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found records do not document signs or symptoms suggestive of structural heart disease; 
the enrollee's dizziness was treated with meclizine. No physical examination is included documenting evidence 
of structural cardiac disease and the review of systems is negative for cardiac symptoms. No imaging or 
electrocardiogram is included to support the request. 
 
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 ultrasound of the heart have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an ultrasound of the heart.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81210 and 81235) 
provided on June 26, 2021. 
 You asked the Plan to pay for the laboratory services. You say that the provider had no advance notice of 
receiving the specimen and was unable to obtain prior authorization. The Plan denied your request. The Plan 
says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code(s): 81210 and 8123 is not supported in the medical record. The member had molecular 
genomics testing on June 26, 2021. The denial remains upheld as non-covered as Medicare denies coverage 
when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 81210 and 81235) provided on June 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been in the hospital since January and you 
need rehab to get back on your feet. The Plan denied your request. The Plan says IRF care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for knee effusion, septic shock, and respiratory failure and your medical problems are stable. There 
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you 
have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you meet IRF criteria. The Plan denied your request. 
The Plan says IRF care is not medically necessary and you can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for surgical management (incision and drainage and fasciotomy) for cellulitis and 
necrotizing fasciitis of the lower extremity and your medical problems are stable. There are no complex nursing 
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Optimizer Smart device for cardiac 
contractility modulation (CCM). 
 
You asked the Plan to pre-approve the Optimizer Smart CCM device. You say that this treatment is shown to 
be helpful in the management of the enrollee's condition. The Plan denied your request. The Plan says the CCM 
device is considered experimental at this time. 
 
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 Optimizer Smart CCM device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is whether implantation of the CCM system in this patient is 
medically necessary for the treatment of (congestive heart failure (CHF) which has been deemed refractory to optimal medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical 
trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional 
capacity.  
 
While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At the current time, the CCM device would not be considered 
medically 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 the Optimizer Smart CCM device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of the Optimizer Smart device for cardiac contractility 
modulation (CCM).