Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the complete denture - maxillary and mandibular partial denture. The Plan 
denied your request. The Plan says your benefit for the complete denture - maxillary 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 complete denture - maxillary was exhausted on date of service July 18, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation services (D4921 x2) provided on March 8, 
2023. 
 
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 the services denied correctly as they do not fall 
within your dental 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, regardless of the providers network status. Therefore, we decided that 
the Plan does not have to pay for gingival irrigation services (D4921 x2) provided on March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939) 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in spine surgery. More research needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee (BK), 
alignable system (L5910). 
 
You asked the Plan to pre-approve an alignable system. You say that the prosthetic is medically necessary. The 
Plan denied your request. The Plan says the notes do not show why your current alignable system cannot be 
used for approved replacement socket. You do not meet criteria for approval of the requested prosthetic. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an alignable system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have a defective socket for your below knee prosthesis. You have a loose and 
poor fitting socket. The endoskeletal system is not reported damaged. Per L33787, the endoskeletal system 
does not need replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition, endoskeletal system, below knee (BK), alignable system (L5910).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the lumbosacral spine 
(72100), therapeutic exercises (97110), electrical stimulation (G0283), and the hot or cold packs therapy 
(97010) provided from March 23, 2023, through March 28, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), x-ray exam of the lumbosacral spine (72100), 
therapeutic exercises (97110), electrical stimulation (G0283), and the hot or cold packs therapy (97010) 
provided from March 23, 2023, through March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for TENS unit supplies provided to the enrollee September. 13, 2022.
You asked the Plan to pay this claim. You say that these supplies should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batterie. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The provider is billing the units in excess of the Medicare allowed amount. Therefore, this claim was denied correctly.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the provider is billing for supplies separately for rented equipment, which is not allowed. The provider is also billing in excess of the normal units allowed by the billing guidelines. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for TENS unit supplies provided to the enrollee September. 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair for the enrollee.
You asked the Plan to pre-approve an electronic connection (E2311). You say that this accessory is medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met. Maximus approved the Plans denial. The Plan requested a reopen and demonstrated that the medical records show the enrollee is independent with self-feeding. The enrollee's upper limb strength and function are adequate to be able to control the power options using their own switches, which are included in the allowance for the approved power wheelchair. As the enrollee is able to the control the power options with their own switches, there is no need to control the power option through the joystick.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. The medical records provided do not show an additional electronic connection (E2311) is medically necessary for the enrollee. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20610 and 29874 billed for date of service 
December 2, 2022. 
 
You asked the Plan to pay for procedure codes 20610 and 29874. You say that this should be paid.  The Plan 
denied your request. The Plan says payment for code 20610 is bundled into payment for code 29881. 
 
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 20610 
is a column II code to column I code 29881. This claim has not been billed with an appropriate modifier to 
bypass the edit.  
 
There is also an edit between column II code 29874 and 29881. This has a modifier indicator of 0, meaning it 
cannot be paid even if a modifier is used. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 20610 and 29874 billed for 
date of service December 2, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the office visit. We decided that the Plan does not 
have to waive the coinsurance for the office visit.  
 You asked the Plan to waive the coinsurance for the office visit provided by an out-of-network provider on 
February 15, 2023. You say that you were told that the provider was in-network. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the office visit.  
   
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan says that you must pay a 40% 
coinsurance for each out-of-network Medicare-covered visit with a primary care provider (PCP), palliative care 
physician, or specialist. The Plan says you must pay more than a 40% coinsurance for the office visit. Based on 
the Plan contract, however, you cannot be asked to pay more than a 40% coinsurance for the office visit. 
Therefore, we decided that the Plan has to reduce the coinsurance for the office visit.  
 
We also decided that the Plan does not have to waive the coinsurance for the office visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for each out-of-network Medicare-covered visit with a primary care provider (PCP), palliative care 
physician, or specialist. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
office visit. 
 
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 a group 3 power wheelchair and accessories (E0953, 
E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0953, E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040, K0861).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514).  
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found [state the medical finding(s) upon which 
the physician based his/her conclusion] 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual electrical stimulation (97032) and an 
ultrasound with electrical stimulation (97035). 
 
You asked the Plan to pre-approve a manual electrical stimulation (97032) and an ultrasound with electrical 
stimulation (97035). You say that it is medically necessary. The Plan denied your request. The Plan says 
Medicare covers chiropractic service is specifically limited to treatment by means of manual manipulation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve a manual electrical stimulation (97032) and an ultrasound with electrical 
stimulation (97035).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 10, 2023, billed with 
codes 87653, 87481, 87150, 87640, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid due to medical 
necessity.  The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 10, 2023, billed with codes 87653, 87481, 87150, 87640, and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 21, 2023, billed with 
codes 81162, 81201, 81272, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81345, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and you have provided medical records to support payment. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 21, 2023, billed with codes 81162, 81201, 81272, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 
81345, and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17313 rendered on January 24, 2023. 
 
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 provider did not bill as required 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, the CPT Code Manual definition of code 17313 is "Mohs micrographic technique, including 
removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, 
microscopic examination of specimens by the surgeon, and histopathologic preparation including routine 
stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue 
blocks." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the pathology service 
was delegated to another provider and therefore the Moh's would not be covered. Per CPT guidelines, Moh's 
should not be reported when two separate providers perform the service.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 17313 rendered on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
accessories (E2377 and E2313), a foot box (E0954) and an adjustable angle footplate (K0040).  
 
You asked the Plan to pre-approve the electronic connection, expandable controller accessories, foot box, and 
adjustable angle footplate. You say that the records provided support the need for the items which remain in 
dispute.  The Plan denied your request. The Plan says the notes do not show a medical need to control the 
power options through the joystick. The Plan says that the power options can be controlled using the enrollee's 
own switches.  
 
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 electronic connection, expandable 
controller accessories, foot box, and adjustable angle footplate. Our reviewer says that the items which remain 
in dispute are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has paraplegia secondary to spina bifida. The enrollee has 4/5 strength in her upper extremities. The 
enrollee has adequate upper body strength to manage standard power drives. 
 
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 electronic connection, expandable controller accessories, foot box, and 
adjustable angle footplate have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an electronic connection (E2311), expandable controller accessories (E2377 and E2313), a foot box (E0954) 
and an adjustable angle footplate (K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on December 22, 2022. 
 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation submitted did not indicate the presence of an independent trained observer during the procedure for the billed services. There 
was documentation that Versed and Fentanyl were administered, however, there was no anesthesiology record 
documenting intraoperative/intra-procedural monitoring of this patient (including blood pressure, heart rate, 
respiratory rate, electrocardiogram, oxygen saturation). The review has determined that the use of CPT 99152 
is not supported by the records provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on December 22, 2022.