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

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) extracellular fluid
analysis for lymphedema assessment for the enrollee.
You asked the Plan to pre-approve this treatment. You say that this treatment is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bioimpedance
spectroscopy (BIS) extracellular fluid analysis for lymphedema assessment. The Maximus Physician Reviewer
determined that all patients with breast cancer with surgery are at risk for lymphedema. BIS is used to assess
lymphedema by measuring limb fluid content as an electric current pass-through cell membranes and tissues.
BIS is used for diagnosis as well as assessing treatment response. BIS is an increasingly utilized diagnostic
technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early
detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard
of care. The service was determined to be reasonable and medically necessary.
The Plan requested a reopen and argues that more research is needed to assess the efficacy of bioimpedance
spectroscopy in the efficacy of identify early lymphedema, and that bioimpedance spectroscopy is not the
standard of care.
The Plan is correct in this case. The medical records show the enrollee is a 71-year-old woman with invasive
ductal carcinoma of the right breast. The enrollee has been treated with lumpectomy and partial breast
radiation. It has been determined that the enrollee is at high risk for the development of lymphedema as a result
of treatment. The evidence regarding the clinical effectiveness of bioimpedance spectroscopy is inconclusive at
this time. Medical necessity has not been established.
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 treatment have not been met. Therefore, we decided that the Plan does not
have to pre-approve bioimpedance spectroscopy (BIS) extracellular fluid analysis for lymphedema assessment
for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 12,
2021 and billed under code 76700.
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, a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between 93976 and 76700. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI
are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code and when necessary, the appropriate modifier.
In this case, this claim cannot be paid as billed due to the omission of the appropriate modifier. 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 medical services provided to the enrollee on October 12, 2021
and billed under code 76700.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging and surgical services rendered on March 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes 32647and 75716 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 36247 (selective catheter placement), 75716 (bilateral
extremity angiography), and 37224 (endovascular revascularization). Codes 36247 and 75716 are column II
codes with a modifier indicator of 1 when billed with column I code 37224. The column II codes were not
billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the imaging and surgical services rendered on March 8, 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 does not require at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. The enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF at this time. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99205) rendered by the out-of-network (OON) provider on September 18, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99205) rendered by the out-of-network (OON) provider on September 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 26, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because this testing was billed correctly. The Plan denied your request. The Plan says this claim was billed with an inappropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 0242U is not supported in the medical record. Specifically, this claim was billed with the laboratory place of service code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on March 31, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says these services were not available for coverage at the time of service.
Maximus overturned the Plans denial stating you were a member of a different Plan in August of 2020, and the
Plan has yet to cover this type of service for you. The Plan requested a reopen and provided documentation
which shows that you have been a member of this Plan since January 1, 20219. The Medicare Beneficiary
Database also shows you have been a member of this Plan since January 1, 2019. The Plan states while you
have changed Plan contract types, you have not changed actual Plans since your enrollment, and you were
covered by this Plan when you exhausted this benefit on August 20, 2020.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these
services once every three years. You had this service covered by the Plan in August of 2020. Therefore, you
were not eligible for the same service to be provided on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on October 24, 
2021 and billed under code 70450. 
 
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 a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists 
between 70496 and 70450. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI 
are allowed, however, an appropriate NCCI modifier was not billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and modifiers. In this case, this claim cannot be paid 
as billed due to the omission of the required modifier. 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 medical services provided to the enrollee on October 24, 2021 and billed under code 70450.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the two crowns (D2740 x2) provided on June 1, 2021. 
 
You asked the Plan to pay for the crowns. The Plan denied your request. The Plan says that a clinical review of 
the documentation submitted for this claim determined the service does not meet the criteria for coverage. 
 
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 record shows that the enrollee received two crowns which were denied for 
not meeting the criteria for coverage. The 2021 Evidence of Coverage states that crowns are limited to two 
procedure codes per calendar year. The provided documentation does not include digital quality x-rays, nor is 
there any documentation showing the enrollee's crowns benefit has been denied. Therefore, we decided that the 
Plan has to pay for the two crowns (D2740 x2) provided on June 1, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 29, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 testing provided on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination provided on September 22, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for a radiologic examination. You say that you are an out-of-network provider, and
the enrollee cannot choose who provides the service. The Plan denied your request. The Plan says 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 a radiologic examination provided on September 22, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0427, A0425) provided on June 8, 2021.
You asked the Plan to pay for the ambulance transportation. You say that these services were necessary and provided at the behest of the enrollee, who still felt as though something was lodged in her throat. The Plan denied your request. The Plan says these services did not meet the criteria for Medicare coverage and are denied as not medically reasonable and necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. The documentation indicates that the enrollee began choking on a piece of food while visiting family, and an ambulance was called. The enrollee was able to clear the obstruction on her own but still felt as though something was in her throat. The record indicates that the enrollee had no chest pain and was able to speak in full sentences by the time the ambulance arrived on scene. She was then transported to the hospital by ambulance.
By the time the ambulance arrived on scene, the present emergency had already passed and there is no documentation that other means of transport would have endangered the enrollee's health. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation services (A0427, A0425) provided on June 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 14, 2020, to September 21, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that it was medically necessary for the enrollee to be treated in an inpatient setting, and this claim should be paid. The Plan denied your request. The Plan says that the criteria for Medicare coverage of inpatient services are not met in this case. The enrollee could have been treated safely and effectively in an observation level of care.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department (ED) on September 14, 2020, with the chief complaint of abdominal pain and vomiting. He had recently had a similar admission for the same symptoms. He responded to medical therapy and was discharged when considered medically stable on September 21, 2020. This review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 14, 2020, to September 21, 2020.
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 continued inpatient psychiatric care.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the requested continued inpatient psychiatric care is medically necessary. The Plan denied your request. The Plan says the requested continued inpatient psychiatric care does not meet criteria.
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 pre-approve continued inpatient psychiatric care. Our reviewer says that the service is not medically necessary. Our physician reviewer found it did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. The enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. The enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hepatobiliary system imaging (procedure code 78227) 
provided to the enrollee on October 25, 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 the place of service billed does not match other claims for the same date of service. 
 
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 78227 is "Hepatobiliary system imaging, including 
gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when 
performed." 
 
We find that CPT code 78227 is not supported in the medical record. Specifically, this was billed with a Place 
of Service (POS) of 22, which indicates outpatient hospital.  
 
 
 However, the claims history shows that the enrollee was inpatient on this date. 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 hepatobiliary system imaging (procedure code 78227) provided to the enrollee on 
October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vision supply, accessory and/or service component 
of another vision code (V2797) provided November 2, 2021. 
 
You asked the Plan to pre-approve the vision supply, accessory or service component of your eyeglasses. You 
say that you would like your lenses paid for. The Plan denied your request. The Plan says your full vision 
benefit has been applied to your claim. 
 
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 up to $100 towards your purchase of frames. This benefit covers standard lenses in 
full.  
 
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. The Plan 
applied $100 towards your vision supply, accessory or component of your eyeglasses. The remaining cost is 
not covered under your benefits. Therefore, we decided that the Plan does not have to pre-approve the vision 
supply, accessory and/or service component of another vision code (V2797) provided November 2, 2021.