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

 
We decided that the Plan does not have to pre-approve low frequency non-thermal ultrasounds (97610). 
 
You asked the Plan to pre-approve low frequency non-thermal ultrasounds. You say that this is a necessary 
treatment for the enrollee, and it is very important they receive it. The Plan denied your request. The Plan says 
this procedure is not covered by Medicare due to lack of evidence. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient scientific or clinical evidence 
to consider this device as reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of low frequency non-thermal ultrasounds have not been met. Therefore, we decided that the Plan 
does not have to pre-approve low frequency non-thermal ultrasounds (97610).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe the enrollee is eligible for the 
SSBCI benefits. The Plan denied your request. The Plan says that the enrollee does not meet the criteria to be 
eligible for SSBCI benefits. 
 
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 did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 24, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface covering system 
(L5962) and dorsiflexion and/or plantar flexion control (L5973). 
 
You asked the Plan to pre-approve a flexible protective outer surface covering system and dorsiflexion and/or 
plantar flexion control. You say that you would like the Plan's denial of the microprocessor foot to be 
overturned. The Plan denied your request. The Plan says this request for prosthesis with microprocessor foot 
does not meet Medicare criteria as reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that code L5962 which will be denied as not reasonable 
and necessary. Medicare rules also say that a microprocessor controlled ankle foot system (L5973) is covered 
for beneficiaries whose functional level is 3 or above. 
 
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 dorsiflexion and/or plantar flexion 
control. Our physician reviewer found the Local Coverage Determination (LCD) for Lower Limb Prostheses 
(L33787) criteria have not been met per documentation that the enrollee is a K3 ambulator. Our reviewer also 
found that therefore, the dorsiflexion and/or plantar flexion control (L5973) exceeds the enrollee's medical 
needs and is not 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 a flexible protective outer surface covering system and dorsiflexion and/or 
plantar flexion control have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
flexible protective outer surface covering system (L5962) and dorsiflexion and/or plantar flexion control 
(L5973).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 14, 2022. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA)/caretaker services from a non-
contracted provider. 
 
You asked the Plan to pre-approve HHA/caretaker services. You say that you were told you could get 35 hours 
of home care due to their medical issues. The Plan denied your request. The Plan says the non-contract 
provider you requested does not provide skilled nursing or physical therapy services. HHA services without 
any other skilled services in place are specifically excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of HHA/caretaker services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health aide (HHA)/caretaker services from a non-contracted provider.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to pay for skilled nursing facility (SNF) services billed for August 3, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan demonstrated that this claim denied
because this service was billed inappropriately. The Plan noted this service should have been billed with
occurrence code 50 for payment consideration. The claim was inappropriately billed with Revenue Code 0022
and without occurrence code 50. The Medicare Claims Processing Manual, Chapter 6, Section 30 states that
effective for claims with dates of service on or after January 1, 2011, there must be an occurrence code 50
(assessment date) for each assessment period represented on the claim with revenue code 0022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim was
not submitted with an appropriate occurrence code. Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services for the
enrollee on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the Minuteman G3R interspinous 
device (20930, 22853, 22612). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is 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 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you were being treated for spinal stenosis of the lumbar region with neurogenic claudication. You 
presented with low back pain. The pain is aching in your lower back and there is numbness in your left foot 
that radiates to the shin. The exam reveals limited range of motion of the knees with varus deformity 
bilaterally. The lateral range of motion of the spine is limited by 15 degrees to the bilateral. 
 
However, current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion.  There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for 
your medical condition. You also have multiple degrees of spinal stenosis, many not at the Food and Drug 
Administration (FDA) indicated levels of moderate spinal stenosis (including the planned level of 
implantation of L4-5). 
 
According to the FDA, the HA Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle supplemental 
fixation device, intended for use at a single level in the non-cervical spine (T1-S1). The HA Minuteman G3-R 
MIS Fusion Plate is intended for use with bone graft material and is not intended for stand-alone use. In 
addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability have 
not been documented and/or met in this case. In addition, there are multiple alternate pain generators plausibly 
significantly contributing to your clinical condition that have not been fully documented as having been 
excluded and/or ruled out. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested implantation of the 
Minuteman G3R interspinous device, in this case, 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the implantation of the Minuteman G3R interspinous device (20930, 22853, 22612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contour next test strips with a contour blood glucose 
monitor (BGM). 
 
You asked the Plan to pre-approve the test strips and BGM. You say that you have arthritis and cannot open the 
bottle for the strips. The Plan denied your request. The Plan says there was no medical documentation showing 
a need for non-preferred products and no documentation showing the enrollee has tried a preferred product 
prior to request. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the test strips and BGM. Therefore, we decided that the Plan does not have to pre-approve contour next test 
strips with a contour blood glucose monitor (BGM).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the fundus photography. We decided that the Plan does not have to pay 
for the contact lenses fitting.  
 
You asked the Plan to pay for the fundus photography and the contact lens fitting provided on November 1, 
2022. You say that you would like the exam procedure resubmitted with the correct procedure code. The Plan 
says that the services are not covered benefits. 
 
We decided that the Plan has to pay for the fundus photography provided on November 1, 2022.  
 
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 fundus photography (92250) is an active code covered by Medicare and not 
appropriate to consider coverage under the Plan's supplemental benefit. The Plan has not shown a valid denial 
of the fundus photography based on Medicare rules.  Therefore, we decided that the Plan has to pay for the 
fundus photography provided on November 1, 2022.  
 
We also decided that the Plan does not have to pay for the contact lens fitting provided on November 1, 
2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers does not cover the contact lens fitting. 
 
We looked at the file and the Plan's rules. Specifically, the contact lens fitting is not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the contact lens fitting have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lens fitting provided on November 1, 
2022. 
 
Please note, the Plan did pay for the routine vision exam. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel provided on November 17, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. In this case, the requested urine PCR panel was billed with multiple 
unbundled codes, rather than a single unit of one code as required by LCA A58710. Based on this information, 
we decided that Medicare rules for coverage of the panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine PCR panel provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for nerve conduction studies provided September 30, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan noted that decision explains that the
2022 edition of ICD-10 Clinical Modification (CM) became active on October 1, 2021. However, M54.50
existed as a diagnosis code prior to the 2022 ICD-10 being active. The Plan notes the services were performed
on September 30, 2021, but the diagnosis code was not in effect during September 2021. This code became
effective on October 1, 2021, per the ICD-10 Coding Manual.
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
could not be paid as billed due to an error with the reported diagnosis code. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for nerve
conduction studies provided to the enrollee on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
November 5, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like these TENS 
supplies to be reprocessed because the criteria has been met. The Plan denied your request. The Plan says 
charges for or in connection with services or supplies that are, as determined by the Plan, considering to be 
experimental or investigational are excluded from coverage. 
 The Plan follows Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, 
the patients medical record must contain sufficient documentation of the patients medical condition to 
substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement 
(if applicable). 
 
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 electrical stimulator supplies. Our 
reviewer says that based on the medical records provided there is inadequate documentation to support that the 
enrollee had a condition which was indicated for coverage for the electrical stimulator supplies (A4595) 
provided on November 5, 2022. Our physician reviewer found provided medical visit notes in this case make 
no mention of the need for or an order for a transcutaneous electrical nerve stimulator (TENS) device. Our 
reviewer also found that although a letter of medical necessity is provided indicating need for the device for 
cervicalgia, the medical visit notes do not support this need. 
 
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 electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on November 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral 
radiographic images (D0210), a partial lower denture (D5214), and a partial upper denture (D5225) provided 
by an out-of-network provider on September 29, 2022, and October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told the provider was an out-of-
network provider and you would like the Plan to cover the dental services. The Plan denied your request. The 
Plan says the comprehensive oral evaluation and the partial lower and upper denture were received from an 
out-of-network provider and are not covered by your supplemental benefits. The intraoral radiographic images 
are not covered by the 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. The record shows you received the comprehensive oral evaluation and the partial lower and upper denture from 
an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the 
requested items or services are not covered under this benefit when received from an out-of-network provider. 
The intraoral radiographic images are not covered under the Plans dental benefit. Therefore, we decided that 
the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral radiographic images 
(D0210), a partial lower denture (D5214), and a partial upper denture (D5225) provided by an out-of-network 
provider on September 29, 2022, and October 11, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 billed for date of service May 31, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the payment 
for this service is included in the fee for the procedure. 
 
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. 
 
In this case, the Plan has not provided information, such as a claim or explanation of benefits, that shows a 
procedure was provided on the date of service at issue. There is insufficient evidence to determine if the 
evaluation service is included in the payment for a procedure. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we 
decided that the Plan has to pay for procedure code 99223 billed for date of service May 31, 2022.  
 
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.