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

 
We decided that the Plan does not have to pay for SNF services provided from December 20, 2021, through 
December 31, 2021. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says December 8, 2021, 
through December 19, 2021, were overturned. The Plan also says that as of December 20, 2021, the enrollee's 
condition no longer required daily skilled 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 pay for SNF services. Our reviewer says that there 
are no identifiable skilled nursing or skilled therapy service needs, and the enrollee did not require skilled 
nursing or therapy services on a daily basis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for SNF services provided from December 20, 2021, through December 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a quantity of ostomy bags beyond those
allowed by Medicare.
You asked the Plan to provide coverage for ostomy bags. You say that the requested quantity is medically
necessary. The Plan denied your request. The Plan says they approved the quantity of ostomy bags allowed by
Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information regarding the requested ostomy quantities.
The Plan stated that the enrollee originally requested 360 or a 6 -month supply (180 days). The original
determination approved the enrollee to receive 120 units for the 6 -month period, consistent with the allowable
limit per LCD L33828. This led to a denial of 240 units. The enrollee appealed the denial of the additional 240
units. On appeal, the clinical information was reviewed by the medical director. This is a.91 -year -old enrollee
who undergoes daily colostomy care following treatment for colon cancer. The enrollee has a history of irritant
dermatitis requiring more frequent changing of the ostomy pouch. The provider documents "No concerns.
Stable, managed well by patient - does require bag change daily to prevent hygiene and infection concerns."
Based on this information, the health plan determined there was an explanation for use of a greater quantity of
supplies then the allowable 20 units per month. The enrollee undergoes daily colostomy care with currently no
concerns and is well managed. Therefore, the health Plan, in addition to the already approving 120 units,
approved an additional 60 units accounting for a total of 180 units. This allows for daily colostomy changes for
the enrollee. The Plan upheld the denial of the additional 180 units (totaling 360), as the medical records do not
support a need for 2 pouches per day.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has quantity limits for ostomy
supplies. The Plan has approved coverage for the maximum number of supplies allowed by Medicare.
Therefore, we decided that the Plan does not have to provide coverage for a quantity of ostomy bags beyond
those allowed by Medicare.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the Plan does not offer a supplemental transportation 
benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without 
contrast (70450) provided on February 11, 2022. 
 
You asked the Plan to pay for CT of the head or brain. You say that the enrollee had multiple exams on the date 
in question. 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, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without contrast 
(70450) provided on February 11, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that IRF care is not medically reasonable and 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee had a recent middle cerebral artery (MCA) stroke with severe aphasia and right hemiparesis, 
and meets the coverage criteria for this admission. The enrollee is medically improving, and needs physician 
supervision three times per week (at a minimum) consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach in an IRF. This admission is reasonable and necessary based on 
medical complexity, nursing needs, and requiring multiple therapies. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 the periodic oral evaluation (D0120), prophylaxis (D1110), 
resin-based composite (D2393), and periodontal maintenance (D4910) provided from February 17, 2020, to 
August 5, 2021. 
 
  You asked the Plan to pay for the periodic oral evaluation, prophylaxis, resin-based composite, and periodontal 
maintenance. You say that you would like to appeal these services. The Plan denied your request. The Plan 
says the claims for the periodic oral evaluation, prophylaxis, and resin-based composite provided on February 
17, 2020, and March 3, 2020 were not submitted in a timely manner. Claims need to be submitted within 
twelve months of the date of service. The Plan says that periodontal maintenance is not a covered expense 
under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 
benefits and provider eligibility. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 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 that claims for the periodic oral evaluation, prophylaxis, and resin-based composite provided 
on February 17, 2020, and March 3, 2020 were not filed until February 23, 2022, and March 16, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. We also 
found that although the Plan offers a dental benefit in excess of Medicare coverage, the periodontal 
maintenance (D4910) is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), resin-based composite (D2393), 
and periodontal maintenance (D4910) provided from February 17, 2020, to August 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) and portable gaseous 
oxygen system (E0431) provided on February 1, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that the oxygen equipment is not related to the 
enrollee's hospice diagnosis. 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 oxygen concentrator (E1390) and portable gaseous 
oxygen system (E0431) provided on February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head, without 
contrast materials (70544) provided on February 20, 2022. 
 
You asked the Plan to pay for the MRA of the head. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70551 and 70544. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head, without 
contrast materials (70544) provided on February 20, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the endosteal implant for tooth 20 provided February 10, 2022. We 
decided that the Plan does not have to pay for the endosteal implant for tooth 19 provided February 10, 2022.  
 
You asked the Plan to pay for an endosteal implant for teeth 19 and 20. You say that it was medically necessary 
to have both implants. The Plan says that you have exceeded the frequency limit for the implant for tooth 19 
and the implant for tooth 20 is not medically necessary. 
 
We decided that the Plan has to pay for the endosteal implant for tooth 20 provided February 10, 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 case file does not include diagnostic quality x-rays for review. Without this 
information we are unable to verify that the Plans denial of the implant for tooth 20 based on medical 
necessity is correct. Therefore, we decided that the Plan has to pay for the endosteal implant for tooth 20 
provided February 10, 2022.  
 
We also decided that the Plan does not have to pay for the endosteal implant for tooth 19 provided 
February 10, 2022. 
 
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 implants once 
per 60 months per quadrant. 
 
We looked at the file and Medicare rules. In this case we have determined that the Plan must provide coverage 
for the implant for tooth 20. Based on this information, we decided that the implant for tooth 20 will exceed the 
Plans frequency limit for coverage of implants in the same quadrant. Therefore, we decided that the Plan does 
not have to pay for the endosteal implant for tooth 19 provided February 10, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wheelchair accessory, manual fully reclining back, 
(recline greater than 80 degrees), (E1226) and Elevating leg rests, pair (K0195). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that attached are all the clinicals needed 
with a letter of medical necessity signed by the doctor to support why the enrollee needed the medical 
equipment. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria for a 
manual fully reclining back rest and elevating leg rests 
 
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 wheelchair accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, the enrollee has a neurologic disorder with functional deficits.  
The criteria for a manual wheelchair are met. The documentation does not indicate that the enrollee has any 
pressure injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or 
recline. There is no indication that the enrollee requires elevating leg rests or a reclining back. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Wheelchair accessory, manual fully reclining back, (recline greater than 80 
degrees), (E1226) and Elevating leg rests, pair (K0195).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac risk assessment genetic screening testing 
provided to the enrollee on March 1, 2021. 
 
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found only the following codes should be billed for Cardiovascular Disease Screening: CPT code 80061 (Lipid 
panel) which includes CPT codes: 82465 (Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct 
measurement; high density cholesterol) and/or 84478 (Triglycerides). The documentation does not indicate 
how the test results will assist in managing the enrollee's condition. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve cardiac risk assessment genetic screening testing provided to the enrollee on March 1, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for morphometric analysis, in situ hybridization (quantitative or semi-
quantitative) each probe (88377) provided November 3, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that please see attached report to support 
payment for 88377. The Plan denied your request. The Plan says that the records provided do not support that 
the testing was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee is a 68-year-old male with multiple myeloma not having 
achieved remission. Multiple Myeloma Panel (CD138) by FISH Diagnosis: Multiple myeloma not having 
achieved remission  FISH MM Interpretation:CD138-selected cells are negative for IGH break-apart, t(4;14), 
t(14;16). t(11;14), t(14;20), t(8;22), 1p deletion, 1q addition, 13q deletion, and numerical abnormalities of 
CEP3, CEP9, and CEP11. Correlation with the results of karyotype analysis is recommended. Tissue Exam on 
10/26/2021: Final Diagnosis: Bone marrow, right posterior iliac crest, core biopsy and particle clot: Mildly 
hypercellular marrow (40-50%) with trilineage hematopoiesis. No morphologic or immunophenotypic evidence 
of plasma cell neoplasm. Myeloma Profile Interpretation: Negative for minimal residual disease (0.0006% of 
total events) in the bone marrow. The review has determined that the items/services at issue in this case are 
medically reasonable and necessary and the records support CPT code 88377 x9 units. 
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for morphometric analysis, in situ hybridization (quantitative or semi-quantitative) each probe (88377) 
provided November 3, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on January 24, 2022. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate 
modifier as required by Medicare rules. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 computed tomography (CT) scan of the head or brain (70450) 
provided on January 24, 2022.