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

 
We decided that the Plan does not have to pay for code 20680-RT-59 billed for date of service June 8, 2023. 
 
You asked the Plan to pay for code 20680-RT-59. You say that this code is documented in the medical record 
and is payable. The Plan denied your request. The Plan says code 20680-RT-59 is not supported by the medical 
record. The operative deport did not include documentation of a removal of a deep implant. 
 
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 20680-RT-59 is Removal of implant; deep (eg, buried 
wire, pin, screw, metal band, nail, rod or plate.  

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 code 20680-RT-59. Our reviewer says that code 20680-RT-
59 is not supported by the medical record. Our reviewer found the procedure report does not include 
documentation of deep implant removal. For CPT 20680, the physician makes an incision overlying the site of 
the implant, dissects deeply to visualize the implant (which is usually below the muscle level and within bone), 
and uses instruments to remove the implant from the bone. This procedure was not found in the operative 
report and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 20680-RT-59 have not been met. Therefore, we decided that the Plan does 
not have to pay for code 20680-RT-59 billed for date of service June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a fixed prosthesis (dental bridge) between teeth
# 7 and #9 (D6245, D6740).

You asked the Plan to provide coverage for a fixed prosthesis (dental bridge) between teeth # 7 and #9 (D6245,
D6740). You say that these dental services are medically necessary. The Plan denied your request. The Plan
says the criteria required for coverage are not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a fixed prosthesis
(dental bridge) between teeth # 7 and #9 (D6245, D6740). The Maximus Dental Reviewer determined that the
documentation provided meets the criteria for coverage for a fixed bridge replacing missing tooth #8 with a
pontic (D6245) using teeth #'s 7 and 9 as abutment retainers (D6740).

The Plan criteria state only exceptional cases with documented physical and/or neurological disorders that
would preclude the use of a removable prosthesis will be considered for a fixed prosthesis. The medical records
provided do not include this documented disorder required for approval. The documentation shows teeth #'s 7
and 8 had crowns with recurrent caries. Tooth #8 was not restorable and required extraction. Tooth #7 required
a new crown. The dental records do not show an exceptional case where there is a documented physical or
neurological disorder that would preclude placement of a removable prosthesis. The documentation does not
support that the coverage criteria for a fixed bridge were met in this case.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a
dental benefit in excess of Medicare coverage, the required coverage criteria are not met. Therefore, we
decided that the Plan does not have to provide coverage for a fixed prosthesis (dental bridge) between teeth # 7
and #9 (D6245, D6740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 2, 
2023, through March 4, 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 the acute inpatient hospital care provided was 
not medically necessary. 
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the hospital with nausea, vomiting, and chest pain. The workup 
revealed pain, non-cardiac in nature, and the symptoms resolved after initial treatment in the emergency 
department (ED). Hyponatremia was also treated with intravenous (IV) fluids, improving sodium levels. His 
vital signs were otherwise stable. There was insufficient support made suggesting that the enrollee would have 
required hospital care that would have likely crossed two midnights or that if treated at a lower level of care, he 
would have had an adverse event.  
 
We looked at this physician's review, the file, and Medicare rules. 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 the acute inpatient hospital care provided from March 2, 2023, through March 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. The Plan denied your request. The Plan says the 
expanded controller component is not needed for the operation of the wheelchair base. 
 
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 electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has adequate 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 an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection. 
 
You asked the Plan to pre-approve an electronic connection. You say that this patient medically requires the 
powered seating functions on their unit to address specific needs. 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 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 electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has adequate 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 an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 You asked the Plan to pre-approve Feraheme. You say that the request is medically necessary. The Plan denied 
your request. The Plan says that step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
criteria for coverage of Feraheme have not been met. Our physician reviewer found the Plan requires a trial of 
two of the following preferred formulary drugs: Ferrlecit, Infed, Venofer before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the Plan's required drug(s) would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve the PET scan. You say that you are requesting reconsideration for the denial 
of a PET scan. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee does not meet the diagnostic 
criteria for both Alzheimer's disease (AD) and frontotemporal dementia (FTD). In as much as the base 
requirement of the NCD for coverage has not been satisfied to date, this request would not be eligible for 
coverage 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost for laboratory services. We decided that the Plan does not have 
to waive the cost for as part of your procedure.  
 
You asked the Plan to waive the cost for an in-network ablation procedure provided on June 23, 2023. You say 
that you should not have any copayments for labs, and this cost share is too high. You've had this done before 
and it wasn't this costly. The Plan says that this cost sharing was charged correctly. We decided that the Plan has to waive the cost for laboratory services.  
 
"The Plan follows Medicare rules. Medicare rules say that you have a $0 copayment for laboratory services.  
 
The file shows that you have a medical indication for which Medicare will cover laboratory services." 
Therefore, we decided that the Plan has to waive the cost for laboratory services.  
 
We also decided that the Plan does not have to waive the cost for as part of your procedure. 
 
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 20% 
coinsurance for surgical/medical supplies and Medicare Part B drugs as part of your procedure. You have been 
asked to pay $2730.19 ($2.16 + $24.24 + $0.18 + $7.99 + $892.69 + $1593.35 + $43.45 + $17.92 + $138.86 + 
$6.72 + $2.63= $2730.19), which is the total of the 20% coinsurance for this procedure. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF criteria. The Plan denied 
your request. The Plan says that the enrollee's condition does not meet Medicare guidelines.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says the request 
for a home mechanical ventilator set in targeted tidal volume, volume-assured pressure support (TTV-VAPS) 
mode with auto-expiratory positive airway pressure that could be delivered by BiPAP is not covered. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from COPD. The record indicates that the enrollee was successfully 
treated with BiPAP.  Our reviewer found that the provided primary source documentation does not contain 
sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be 
treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability and failure 
of such a device has not been documented. Our physician reviewer also found that the Plan has indicated 
coverage for such a device is available upon request. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99219 billed to the enrollee for September 
5, 2022.

You submitted a claim for payment of code 99219. The Plan denied your request. The Plan says the 
Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim 
information in the file. The Plan requested a reopen and provided the required claim information. 
The Plan noted that code 99219 is an initial observation code for the hospital physician and can 
only be billed by one physician. The Plan states the second claim was denied as code 99219 was 
previously billed for the same enrollee for the same date of service.

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, there is no indication the second claim was for a separate and distinct service. Code 
99219 can only be billed to an enrollee once for the same date of service. 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 pay for code 99219 billed to the enrollee for September 5, 2022.
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 enrollee is ready for discharge to inpatient 
rehabilitation and meets both medically necessary and Medicare criteria. The Plan denied your request. The 
Plan says the IRF services requested do not meet the requirements for approval.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical or occupational therapy, at an 
intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours 
a week, under the supervision of a physician with at least three visits weekly to regain or maintain their 
functional status. The enrollee can receive further services at a lower level of care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy (53854). 
 
You asked the Plan to pre-approve transurethral destruction of prostate tissue. 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 transurethral destruction of prostate 
tissue. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy is not medically reasonable and necessary in this case. The records do not show that the prostate volume is 30-80 cc as measured by ultrasound as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral destruction of prostate tissue have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy (53854).