Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for integrated biopsychosocial assessment, including history, mental status, 
and recommendations provided by you, on August 26, 2021. 
 
You asked the Plan to pay for integrated biopsychosocial assessment, including history, mental status, and 
recommendations. The Plan denied your request. The Plan says that the Plan could not make a decision within 
the timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supported the reason for denial of payment of the 
claim. Therefore, we decided that the Plan has to pay for integrated biopsychosocial assessment, including 
history, mental status, and recommendations provided by you, on August 26, 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: Drugs
Decision: Favorable

We decided that the Plan has to provide coverage for Brovana (Arformoterol Tartrate) (J7605) for the enrollee.
You asked the Plan to provide continued coverage for this drug. You say that continuation of this drug is
medically necessary. The Plan denied your request. The Plan says that their step therapy criteria was not met.
Maximus upheld the Plans denial. After we made our decision, we reopened the case due to an error discovered
after a second review with our Medical Director.
Our Medical Director looked at the case file. At issue is coverage for Brovana (Arformoterol Tartrate). The
enrollee has a diagnosis of moderate persistent asthma with status asthmaticus. The office note dated June 6,
2022, documents, "Reviewing her inhaled regimen she is only on Brovana per nebulizer and albuterol puffer."
The enrollee's medication list includes arformoterol (Brovana) 15 mcg/2 mL nebulizer. Step therapy may only
be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving
the affected medication. The clinical documentation in the case file supports that the enrollee is actively
receiving the requested medication. Therefore, the Plans step therapy criteria do not apply.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for of this drug have been met. Therefore, we decided that the Plan has to provide coverage for
Brovana (Arformoterol Tartrate) (J7605) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp debridement (D3221) provided by a participating 
provider on February 9, 2022. 
 
You asked the Plan to pay for pulp debridement. You say that this service should be covered because it was 
part of the root canal. The Plan denied your request. The Plan says the rendered dental service is not a covered 
benefit. 
 
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 pulp 
debridement (D3221) provided by a participating provider on February 9, 2022.  
 
A limited oral evaluation (D0140), and intraoral imaging (D0220) are not being addressed in this appeal. These 
services were approved and paid.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ECG interpretation (93042) provided on December 16, 
2021. 
 
You asked the Plan to pay for the ECG interpretation (93042). The Plan denied your request. The Plan says 
procedure code 93010 has been overturned and a modifier cannot be billed with procedure code 93042 to 
bypass the edit. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the ECG interpretation (93042) provided on December 16, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the emergency department visit provided on November 
8, 2021. 
 
You asked the Plan to pay more for the emergency department visit. You say that the patient presented to the 
emergency department with a potentially emergent medical problem and treatment was provided. You say that 
you are requesting review of the emergency record and for the claim to be approved at the appropriate 
reimbursement rate for the code billed. The Plan denied your request. The Plan says the documentation does 
not support CPT code 99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
  1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 more for the emergency department visit Our 
reviewer says that the documentation does not support the originally billed CPT code 99285. Our reviewer 
found that the enrollee was treated and discharged the same day with prescriptions and was referred to an 
outpatient urology clinic. CPT code 99285 requires a comprehensive history, a comprehensive examination and 
medical decision making of high complexity. The medical decision making in this case was not of high 
complexity. 
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay more for the emergency department visit provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator (L8680, 63650). 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that the spinal cord stimulator is 
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 spinal neurostimulators are covered when 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 spinal cord stimulator. Our reviewer 
says that this service is medically necessary. Our physician reviewer found the enrollee has post cervical 
laminectomy syndrome for more than 10 years. She takes Suboxone, Gabapentin and Naproxen for pain. She 
has had 2 Cervical Epidural Steroid injections without sustained benefit. She has psychological clearance for a 
neurostimulator trial. Coverage criteria has been 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 spinal cord stimulator have been met. Therefore, we decided that the Plan 
has to pre-approve a spinal cord stimulator (L8680, 63650).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient behavioral health services provided to the enrollee 
from July 16, 2021, to September 1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these services were not authorized. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that based on a 
review of the records provided, it was not expected that this enrollee would improve in a reasonable period of 
time, as he did not have dangerousness to self or oters, auditory or visual hallucinations, delucions, and was not 
showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care. The health plans denial of 
inpatient psychiatric services appears appropriate. 
 
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 pay for inpatient behavioral health services provided to the enrollee from July 16, 2021, to September 
1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - mandibular (D5120) provided 
February 3, 2022. 
 
You asked the Plan to pay for the complete lower denture. You say that the Plan told you the dentures would be 
covered. The Plan denied your request. The Plan says that the provider called to ask about benefits in 2021, 
five months prior to the services being rendered. At the time the provider called, the dentures were covered 
under your 2021 plan. You changed plans in 2022 and dentures are not included in your 2022 benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
complete denture - mandibular (D5120) provided February 3, 2022.  
 Your complaint about feeling misled about your coverage is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit provided on September 9, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the records should be reviewed as 
they support processing the claim for payment. The Plan denied your request. The Plan says that evaluation and 
management codes are not covered for this specialty or provider type. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided a valid rationale for why the rendering provider type 
is not an appropriate provider for emergency services. The provider at issue in this case is a doctor that 
specializes in emergency medicine. This is a valid provider type for emergency services. Therefore, we decided 
that the Plan has to pay for the emergency department visit provided on September 9, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on February 
23, 2022. 
 
You asked the Plan to pay for the mandibular partial denture. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as you 
have already met your $1,000 dental allowance for the year and pay 100% for services once that's met. 
 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
mandibular partial denture (D5214) provided on February 23, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not meet criteria for SNF care and the enrollee's ongoing 
skilled care can be provided in an alternative setting such as in a long-term care facility or at home with home 
health services. 
 
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 physician reviewer 
found that the enrollee does have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
  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: 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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 enrollee was admitted for non-surgical management of a vertebral compression 
fracture. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-complete series of radiographic images provided on 
February 21, 2022. 
 
You asked the Plan to pay for intraoral-complete series of radiographic images. You say that you would like 
the x-rays covered and the provider did not know they would not be. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because one complete series of radiographic images is 
covered every 5 years and you previously received a complete series of radiographic images on May 23, 2019. 
 
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 one complete 
series of radiographic images every 5 years. 
 
  We looked at the file, the Plans rules, and Medicare rules. You previously received complete series of 
radiographic images on May 23, 2019; therefore, the benefit was exhausted for date of service February 21, 
2022. Therefore, we decided that the Plan does not have to pay for intraoral-complete series of radiographic 
images provided on February 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the antigen therapy services provided on August 17, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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 95165 is professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses). 
 We find that CPT code 95165 is not supported in the medical record. Specifically, the records do not include a 
plan of treatment or a dosage regimen by the physician who prepared the antigens. 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 antigen therapy services provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fitting and insertion of pessary or other intravaginal 
support device (57160), provided on November 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the fitting and insertion of pessary or other intravaginal support device. You say 
that the service should be covered. The Plan denied your request. The Plan says the service was obtained out-
of-network. 
 
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 fitting and insertion of pessary or other 
intravaginal support device (57160), provided on November 30, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition, endoskeletal system, below knee, alignable system 
represented by code L5910. 
 
You asked the Plan to pre-approve code L5910. You say that the enrollee is getting sores on his legs and that 
the requested item is medically necessary. The Plan denied your request. The Plan says that the enrollee's 
current socket included L5910, and the notes do not show that it is damaged beyond repair or cannot be re-
used. 
 
The Plan follows Medicare rules. Medicare rules say that the replacement of a device or part is covered for 
certain clinical indications and when 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 code L5910. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee has a had a right below knee 
amputation and has been using a prosthesis. The enrollee's residual lib has changed shape. The clinical 
documentation shows that all potential modifications have been trialed. The clinical documentation specifically 
justifies the L5910 alignment system and medical necessity has been shown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code L5910 have been met. Therefore, we decided that the Plan has to pre-
approve an addition, endoskeletal system, below knee, alignable system represented by code L5910.  
 
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.