Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary for the enrollee. The Plan denied your request. The Plan says the required Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted
that Maximus did not apply the correct criteria. The medical records do not reflect a need for close care (face to
face visit at least 3 days a week) from a physician specializing in the field or Physical Medicine and
Rehabilitation.

The Plan notes that while it is true the enrollee has multiple health conditions, the records do not show the need
for care in an IRF facility.

The Plan is correct in this case. 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. Based
on the medical records provided, the enrollee did not require an inpatient rehabilitation level of care. Medicare
rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide
coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for any of the requested dental services.

You asked the Plan to provide coverage for these dental services. You say that at the time of the appeal, these
services were medically necessary. The Plan denied your request. The Plan says the medical records do not
support that an exceptional medical condition was present to allow coverage of these services. Maximus
partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

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.

Though the Plan offers a dental benefit Medicare does not, the medical records provided do not specifically
indicate exceptional medical conditions exist that would allow coverage for these benefits. The original
Maximus physician reviewer also does not indicate such a condition exists. Therefore, we decided that the Plan
does not have to provide coverage surgical placement of implant body: endosteal implant (D6010) Tooth # 22
and 27, custom fabricated abutment-includes placement (D6057) Tooth # 22 and 27, LW-overdenture-complete
mandibular (D5865), surgical access to an implant body (second stage implant surgery) (D6011) Tooth # 22
and 27 and alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
(D7310) x2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service March 18, 
2023, to April 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical literature substantiates the efficacy of 
the treatment rendered. The Plan denied your request. The Plan says the billed code is not covered. 
 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 E0675 is pneumatic compression device, high pressure, 
rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system). 
 
We find that CPT code E0675 is not supported in the medical record. The records show that the enrollee has a 
history of lymphedema. The device at issue was provided to accelerate post-operative healing and to reduce 
complications. The provided device is not covered for these indications. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code E0675 billed for dates of service March 18, 2023, to April 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 billed for date of service June 9, 2023.  
 
You asked the Plan to pay for procedure code 69209. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 69209 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 69209 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 69209 billed for date of service June 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service January 4, 
2023. 
 You asked the Plan to pay for procedure code 99283. You say that this was a separate service. The Plan denied 
your request. The Plan says payment for code 99283 is bundled into payment for code 99285. 
 
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 99283 
is a column II code to column I code 99285. 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 procedure code 99283 billed for date of service January 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for long term acute care hospital (LTACH)
services.

You asked the Plan to provide coverage for LTACH services. You say that at the time of the appeal, LTACH
services were medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee
was receiving an appropriate inpatient level of care at the admitting facility at the time of the appeal. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that LTACH services are
covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the
enrollee. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general,
LTACHs do not provide clinical services that are materially different than those of short-term acute care
hospitals. The documentation does not support that the enrollee required services at the LTACH that were not
available at the acute care hospital where the enrollee was receiving care.

There are no required medical services identified that were available at the LTACH, that were not available at
the health care setting offered by the health plan. Consequently, the requested LTACH services were not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at that time.
Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been
met. Therefore, we decided that the Plan does not have to provide coverage for long term acute care hospital
(LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower cost share for Tezspire (J2356). 
 
You asked the Plan to pre-approve a lower cost share for Tezspire. You say that the enrollee has tried multiple 
medications. You also say that the enrollee is still having almost daily asthma exacerbations. The Plan denied 
your request. The Plan says tiering exceptions are only available for drugs billed on the Medicare Part D 
(Pharmacy) benefit. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The drug(s) you are requesting is considered a Part B drug. As a 
result, no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve a 
lower cost share for Tezspire (J2356).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31500 billed for May 12, 2023. 
 
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 code 31500 is not supported. 
 
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 31500 is intubation, endotracheal, emergency procedure. 
 
We find that CPT code 31500 is not supported in the medical record. Specifically, there is no documentation of 
an emergency endotracheal intubation for the date of service at issue. 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 procedure code 31500 billed for May 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx. 
 
You asked the Plan to pre-approve Cosentyx. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx.  Benefits for Cosentyx may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care billed with the Health Insurance 
Prospective Payment System (HIPPS) code 2EC31 for June 15, 2022, to July 14, 2022. 
 
You asked the Plan to pay for home health care billed with 2EC31. You say that 2EC31 was billed correctly. 
The Plan denied your request. The Plan says due to the previous admission in this period, 4EC31 is the 
appropriate HIPPS code. 
 
The Plan follows Medicare rules. The rules say that the first position of the Health Insurance Prospective 
Payment System (HIPPS) code represents a combination of the referral source (community or institutional) and 
the period timing (early or late). A 2 in the first position indicates Institutional Early and 4 indicates 
Institutional Late. 
 
The record shows that the enrollee had an episode of home health care less than 60 days prior to the home health care at issue, supporting the paid HIPPS code of 4EC31 rather than 2EC31. Therefore, we decided that 
the Plan does not have to pay for home health care billed with the Health Insurance Prospective Payment 
System (HIPPS) code 2EC31 for June 15, 2022, to July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Freestyle 14-day reader.

You asked the Plan to provide coverage for a Freestyle 14-day reader. You say that at the time of the appeal, a
Freestyle 14-day reader was medically necessary. The Plan denied your request. The Plan says at the time of
the appeal, you did not use insulin, therefore the required criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that you did not use insulin with at least
three daily injections at the time of the appeal. Based on this information, we decided that Medicare rules for
coverage of a Freestyle 14-day reader were not met. Therefore, we decided that the Plan does not have to
provide coverage for a Freestyle 14-day reader.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus did not apply the
correct criteria. The Plan stated the medical records show as of May 29, 2023, you were ambulating 140 feet
with a rolling walker and contact guard assist. You had no problems putting on or taking off the prosthesis.
You needed moderate assistance with sit-to-stand and minimum assistance or better with the other therapy
modalities.

You did not have any complex medical, nursing, or rehabilitation needs. You were discharged from the hospital
to a skilled nursing facility (SNF) on May 30, 2023. SNFs (also known as subacute rehabilitation) provide
rehabilitation care to stroke survivors who need daily skilled nursing or rehabilitation services. IRFs provide
hospital-level care to stroke survivors who need intensive, 24-hour-a-day, interdisciplinary rehabilitation care
that is provided under the direct supervision of a physician. At the time of the appeal, you did not need
intensive, 24-hour-a-day interdisciplinary rehabilitation care.

The Plan is correct in this case. 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.
Based on the medical records provided, you did not meet the criteria required for an IRF admission.
Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility
(IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 Sprint PNS. Our reviewer says that 
the requested Sprint PNS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental. Therefore, the reviewer found that the requested Sprint PNS is 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge (D6240 x 3, D6750 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you trust your providers treatment plan and 
are appealing the denial. The Plan denied your request. The Plan says that the long-term prognosis is poor due 
to the poor periodontal condition. 
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the documentation indicates that 
due to the poor periodontal condition of the abutment retainers which exhibit bone loss greater than 50% and 
the poor bone support of the remaining implants in the lower arch the criteria for coverage for a fixed bridge 
replacing missing teeth number's 24, 25 and 26 have not been met.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed bridge (D6240 x 3, D6750 x 3).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 26, 2023, to June 
14, 2023. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial. 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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The claim was billed 
with an invalid type of bill. We find the Medicare rule for payment of this April 26, 2023, through June 14, 
2023, claim has not been met. Therefore, we decided that the Plan does not have to pay for home health 
services provided from April 26, 2023, to June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Percutaneous Image-Guided Lumbar Decompression 
(PILD) services coded as 0275T performed on date of service February 6, 2023. 
 
You asked the Plan to pay for the PILD services. You say that the PILD services should be paid as billed 
because they are supported in the record and clinical trial number 03092927 is included on the claim. The Plan denied your request. The Plan says the PILD services are denied because they were not billed with a valid 
clinical trial number. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that contractors shall pay for 
PILD only when billed with the numeric, 8-digit clinical trial identifier number. Claims billed without a clinical 
trial identifier number shall be returned as not processable. 
 
We looked at the file and Medicare rules. According to Medicare, the clinical trial number reported for the 
PILD services in this case, 03092927, is not one of the approved trials for this procedure, therefore it is not 
valid. Based on this information, we decided that Medicare rules for coverage of the PILD services have not 
been met. Therefore, we decided that the Plan does not have to pay for the Percutaneous Image-Guided Lumbar 
Decompression (PILD) services coded as 0275T performed on date of service February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 13, 2023. 
 
You asked the Plan to pay for lab test. You say that the records support medical necessity. The Plan denied 
your request. The Plan says this claim was not billed with the appropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS) code.  
 
We looked at the file and Medicare rules. This claim was billed with POS code 81  indicating an independent 
laboratory setting  however, the records do not support that the sample for this testing was taken directly in 
the independent laboratory. Based on this information, we decided that Medicare rules for coverage of lab test 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on 
June 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on 
September 28, 2022, to October 27, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 31, 2022. The NOA was not received by the Plan until February 22, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0299, 
Q5001) provided on September 28, 2022, to October 27, 2022.