Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated knee orthosis (L1852).
You asked the Plan to pre-approve a prefabricated knee orthosis. You say that your doctor wants to try this because you are immobile without it. The Plan denied your request. The Plan says that the records do not show that you have knee instability present on examination. Maximus overturned the Plan's denial. The Plan requested a reopening 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 prefabricated knee orthosis.
Our Medical Director states that the documentation does not support that the coverage criteria for a knee orthosis (L1852) were met in this case. Our physician reviewer found that your condition does not meet Medicare criteria for a prefabricated knee orthosis. 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 prefabricated knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a prefabricated knee orthosis (L1852).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 87900 and 87899 billed for date of service March 28, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid for dinner. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and demonstrated that this claim denied because this service does not meet the criteria for the category under which it was billed. Code 87899 is defined as Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; not otherwise specified. There is no documentation provided to support that direct optical observation was performed. Records support that an Infection Panel test was performed of multiple organisms and antibiotic resistance however, there is no documentation to indicate that a separate test via direct optical observation utilizing reagents was performed for a visual reaction. Code 87900 is defined as Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. The description further explains the medical records must contain "quantitative prediction of drug susceptibility phenotype."
Per medical records attached, there is no documentation of a quantitative prediction of drug susceptibility phenotype and provided numeric measure of susceptibility or resistance on which to base the selection of drug regimens.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The question was not whether the records supported that the codes in question were performed, but whether they were medically appropriate. The Plan is correct that the records provided do not document quantitative prediction of drug susceptibility phenotype nor did they provide numeric measure of susceptibility or resistance on which to base the selection of drug regimens. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for codes 87900 and 87899 for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on November 10, 2022. 
 
You asked the Plan to pay for a rest home visit. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a rest home visit 
provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 28, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the Plan has to pay 
for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-
approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for the laboratory services based on Medicare criteria. Therefore, we decided that the 
Plan has to pay for the laboratory services provided on April 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the therapeutic exercises (97110), massage 
therapy (97124), and the unlisted special procedures (99199) provided from September 17, 2022, through 
December 12, 2022. 
 
You asked the Plan to issue reimbursement 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 services 
provided do not meet criteria for coverage.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for outpatient rehabilitation therapy 
services only when provided by those trained specifically in physical therapy, occupational therapy or speech-
language pathology. Additionally, the Plans contract says that supplemental coverage is provided for massage 
therapy only when rendered by a chiropractor.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, Medicare pays for outpatient rehabilitation therapy 
services only when provided by those trained specifically in physical therapy and occupational therapy. In this 
case, the therapy services were provided by an acupuncturist. Additionally, supplemental coverage is provided 
by the Plan for massage therapy only when rendered by a chiropractor. The massage therapy services provided 
in this case were rendered by an acupuncturist. Therefore, we decided that the Plan does not have to pay for the 
therapeutic exercises (97110), massage therapy (97124), and the unlisted special procedures (99199) provided 
from September 17, 2022, through December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110/D5120) provided on February 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you lost your old dentures. The Plan denied 
your request. The Plan says your benefit for the requested item or service 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 Plans 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 requested item or service was exhausted on date of service August 17, 2020. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110/D5120) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two dental extractions (D7140) provided on December 20, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says your annual dental maximum allowance amount 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 Plans 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 dental annual maximum allowance amount of $2,000 was exhausted on date of service December 
20, 2022. Therefore, we decided that the Plan does not have to pay for two dental extractions (D7140) provided 
on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam CT (D0367). 
 
You asked the Plan to pre-approve cone beam CT. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered 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. 
 
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. Therefore, we decided that the Plan does not have to pre-approve cone 
beam CT (D0367).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on April 18, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Medicare guidance allowing for payment on emergent 
hospital claims for non-Medicare certified hospitals does not apply to non-Medicare freestanding emergency 
facilities.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital.  
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on April 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided on March 16, 
2021. 
 
You asked the Plan to pay for the ER services. You say that the services should be covered. The Plan denied 
your request. The Plan says the claim was filed untimely. 
 
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. 
 
The record shows that a claim for the ER services was not filed until March 14, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the emergency room (ER) services provided on March 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health services. 
 You asked the Plan to pre-approve home health services. You say that the enrollee is still in need of the 
services. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled nursing needs. As such, home health skilled nursing services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker, heavy duty, multiple braking system, variable 
wheel resistance (E0147). 
 
You asked the Plan to pre-approve a walker. You say that you disagree with the denial and have submitted 
medical records to support medical necessity. The Plan denied your request. The Plan says you have a transient 
condition of the left wrist which per the notes, is improving and does not constitute a chronic restriction of use 
of the hand. You do not meet criteria for approval of the requested walker. 
 
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 a walker. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the upright walker at 
issue in this case meets all Medicare criteria for you. Provided records in this case do not document that you are 
unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use 
of one hand. Although records report tendonitis of your left wrist and forearm, records do not document 
restricted use of the hand on examination (5/5 strength noted and no hand issue reported on extremity exam). 
 
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 walker have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a walker, heavy duty, multiple braking system, variable wheel resistance (E0147).
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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for leg wound, peripheral artery disease, and an above the knee amputation. Medical problems are 
stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 
 
There is not a reasonable expectation that you 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 pay for the oxygen concentrator (E1390) provided to the enrollee on September 17, 2022.
You asked the Plan to pay for the oxygen concentrator. You say that the item was medically necessary. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed.
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on October 4, 2022. The file confirms a different provider submitted an identical claim for the same enrollee and the same date of service, that has already been paid by the Plan. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided to the enrollee on September 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on October 24, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan notes that that claim denied because this provider was not certified or eligible to be paid for this type of procedure or service. The rendering provider is an individual physician and cannot bill for Opioid Treatment Program Services. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The provider billed for individual services that would normally be covered in the payment to the facility. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing billed for date of service May 
5, 2022. 
 You asked the Plan to pay for the billed services. You say that the results allow physicians to make treatment 
decisions. The Plan denied your request. The Plan says the clinical effectiveness has not been effective. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The provided pharmacogenetic testing was ordered to make decisions 
about the enrollees medications. Medications should be provided based on the presence of a diagnosis and 
should be adjusted based on a response to the medication. It is not necessary to do genetic testing to provide or 
adjust medications. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing billed for date 
of service May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture-maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your $500 annual maximum has been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve complete denture-maxillary (D5110).