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

 
We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) provided on February 8, 2023.  
 
You asked the Plan to pay for the AFO. You say that this was medically necessary and should be paid.  The 
Plan denied your request. The Plan says payment was approved for the procedure; however, the POS code for 
the DME is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that DME may be covered when the claim is billed 
with the POS code of the location in which the DME will be primarily used. 
 
We looked at the file and Medicare rules. In this case, the DME was billed with the office POS code, not the 
home POS code as required. Based on this information, we decided that Medicare rules for coverage of the 
AFO have not been met. Therefore, we decided that the Plan does not have to pay for the ankle-foot orthosis 
(AFO) provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy (D4212) for tooth #23 provided on April 10, 2023.

You asked the Plan to pay for the dental service. You say that the Plan told you that the provider was an in-network provider, and you were referred by the in-network provider for the dental services. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the gingivectomy is not covered by the Plan.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingivectomy (D4212) for tooth #23 provided on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 27, 2022, described by 
codes 81307 and 81351. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and should be 
paid.  The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 27, 2022, described by codes 81307 and 
81351.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient L4 kyphoplasty (22514 and 76937). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical necessity coverage criteria are not 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 the services. Our physician reviewer 
found that there is no trial of a fracture brace. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the outpatient L4 kyphoplasty (22514 and 76937).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition to lower extremity, below knee, acrylic 
socket and a custom shaped protective cover, below knee (L5704 and L5629). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the items are not medically necessary. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found although there is documentation of the need for a below the knee prosthesis, based on the 
medical records provided there is no documentation from the enrollee's treating physician that the addition to 
lower extremity, below knee, acrylic socket and a custom shaped protective cover, below knee (L5704 and 
L5629) are medically reasonable and necessary 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the addition to lower extremity, below knee, acrylic socket and a custom shaped protective 
cover, below knee (L5704 and L5629).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Orthofix Trinity Elite allograft and continuous intraoperative neurophysiology monitoring (95941).
You asked the Plan to pay for Orthofix Trinity Elite allograft and continuous intraoperative neurophysiology monitoring (95941). The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus partially overturned the intraoperative monitoring. The Plan requested a reopen and noted the intraoperative monitoring coded as 95941 was denied due to a coding issue.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In regard to the intraoperative monitoring, code 95941 has a status code of "I" and is not a valid code for Medicare claims. The appropriate code would have been G0453 (which reflects monitoring just one patient at a time which is in accordance with Medicare regulations). Medicare coding criteria are not met. Therefore, we decided the Plan does not have to provide coverage for intraoperative monitoring under code 95941.
In regard to Orthofix Trinity Elite allograft, our physician reviewer found based on the medical records, Trinity allograft has not been established to be medically 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 Orthofix Trinity Elite allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthofix Trinity Elite allograft.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87500, 87640 and 87641) provided to the enrollee on August 1, 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 coverage criteria were not met. Maximus partially overturned the Plans denial and only upheld code 87640. The Plan requested a reopen and noted that the records do support code 87641 but did not support code 87500. The Plan has paid procedure code 87641 and denied code 87500 as the records provided 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 code. We have confirmed that code 87640 is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to bypass the edit. Medicare billing criteria have not been met for payment. Therefore, the Plan does not have to pay for code 87640.
Regarding codes 87641 and 87500, code 87641 has now been paid by the Plan. We also agree with the Plan that code 87500 is not supported by the records submitted.
Therefore, we decided that the Plan does not have to pay for lab services (87500 and 87640) provided to the enrollee on August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on October 7, 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 partially overturned the Plans denial for insufficient information. The Plan requested a reopen and provided documentation to show codes 82043, 82533, 82570, 82627, 82670, 82747, 83003, 83525, 83735, 83970, 84144, 84146, 84270, 84305, 84403, 84439, 84443, 84481, 84550, 84681, 86141, 80053, 80061, 85025, 82172, 83695 and 83698 were handled separately.
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 83721 is a column II code to column I code 80061. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 83721. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below knee flex cover system (L5962) for the enrollee.
You asked the Plan to pre-approve a below knee flex cover system. You say that this is medically necessary. The Plan denied your request. The Plan says that the records provided do not indicate that the enrollee is exposed to harsh conditions or engages in extraordinary activities that require extra protection from a specialized prosthetic cover.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a below knee flex cover system.
Our Medical Director states that the documentation does not support that the enrollee has a special need for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of a below knee flex cover system. 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 below knee flex cover system have not been met. Therefore, we decided that the Plan does not have to pre-approve a below knee flex cover system (L5962) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87481, 87640, 87653, 87150,87500, and 87798) provided to the enrollee on December 22, 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 Medicare billing criteria are not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that a test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. Medicare's considers the stacking of codes unacceptable.
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, this claim could not be paid as billed as these services are covered by one panel code and cannot be separately billed.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87481, 87640, 87653, 87150,87500, and 87798) provided to the enrollee on December 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 26, 2022, and billed under codes 75860 and 76937.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan provided documentation to show those codes overturned were paid.
In regard to codes 75860 and 76937 these codes could not be paid due to billing errors. Code 75860 is a column II code to column I code 75898. 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. Code 76937 is not supported by the medical records submitted. Therefore, we decided the Plan does not have to pay for imaging services provided to the enrollee on October 26, 2022, and billed under codes 75860 and 76937.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiological services provided on May 7, 2022, and billed under codes 93010 and 76937.
You asked the Plan to pay this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information.
The Plan demonstrated that the records submitted records supported codes 31500, 36556, and 99291. Those codes have been reprocessed and paid by the Plan. The records do not support codes 93010 and 76937.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Code 93010 is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to bypass the edit. Therefore, the Medicare billing criteria have not been met. Code 76937, defined as "ultrasound guidance for vascular access requiring ultrasound evaluation of potential access site", is not supported by the records provided and remains denied. Therefore, we decided that the Plan does not have to pay for radiological services provided on May 7, 2022, and billed under codes 76937 and 93010.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty at level T12-L1. 
 
You asked the Plan to pre-approve the kyphoplasty at level T12-L1. You say that the surgery is medically 
necessary and that the enrollee meets all the criteria. The Plan denied your request. The Plan says the 
kyphoplasty is not medically necessary. The Plan says the records do not show that the enrollee failed non-
surgical medical management, including physical therapy. 
 
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 kyphoplasty at level T12-L1. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record shows T12 has only 20 % height loss and L1 has only 10%. This 
means that there is not enough vertebral bony height loss to justify kyphoplasty. 
 
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 kyphoplasty at level T12-L1 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the kyphoplasty at level T12-L1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch ultra test strips.
You asked the Plan to pre-approve OneTouch ultra test strips. You say that you need to check your blood sugar 4 times a day. The Plan denied your request. The Plan says only the preferred brand products listed in the ANOC are covered. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional Plan documents.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.
Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits. We looked at the file and Medicare rules. According to the ANOC, the requested brand is not a preferred brand for OneTouch ultra test strips. Therefore, we decided that the Plan does not have to pre-approve OneTouch ultra test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace provided on September 12, 2022.
You asked the Plan to waive the coinsurance for the back brace. You say that the provider's office told you there would be no charge for the back brace. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional claim documentation.
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 Medicare-covered prosthetic devices and supplies.
You have been asked to pay a 20% coinsurance of $179.41 for the back brace. This item/service falls within the Medicare-covered prosthetic devices and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the back brace provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 29, 2022, described by 
code 81345. 
 
You asked the Plan to pay for the lab services. You say that this should be paid. The Plan denied your request. 
The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 29, 2022, described by code 81345.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve both Epifix and Epicord for wound treatment.
You asked the Plan to pre-approve Epifix and Epicord. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 both Epicord (4187) and Epifix (4186) skin substitutes. Based on the medical records provided, there is insufficient documentation to show that the wound is not healing with standard wound therapy. Subsequent measurements are not provided to show that the wound is not healing. Finally, more than one skin substitute product at a time for the same wound is not considered medically reasonable and 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 this treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve both Epifix and Epicord for wound treatment.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve semi-precision attachment placement (D6192) services. 
 
You asked the Plan to pre-approve codes D6192. You say that the purpose of the overdenture is for retention, 
not support.  The Plan denied your request. The Plan says that for the requested service to be approved, more 
than half of the enrollee's tooth must be damaged due to decay or injury. The Plan says that the records that 
were sent do not show signs of more than half of the tooth being damaged from decay or injury. The Plan says 
that the services which remain in dispute are not medically necessary.  
 
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. The Plan covers codes D6192 
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 codes D6192. Our reviewer says that 
the criteria for coverage have been met.  Our physician reviewer found it is medically reasonable for D6192 for 
teeth numbers 5 and 13 to be approved, as these dental procedures are part of the overdenture procedure. 
D06010 and D6191 for teeth numbers 5 and 13 have been approved previously as noted in a letter from Aetna 
dated August 3, 2023. If D6010 and D6191 have been approved for teeth numbers 5 and 13, D6192 should also 
be approved as all three of these procedures are done in conjunction with one another. There is no possibility of 
overdenture retention without these dental procedures. D6191 and D6192 are attachment pieces that come 
together. The enrollee is missing many of her posterior teeth. An implant overdenture would help the enrollee 
have a better quality of life as it would allow her to eat her food better and therefore aid in the digestion and 
absorption of nutrients. 
 
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 codes D6192 have been met. Therefore, we decided that the Plan has to pre-
approve semi-precision attachment placement (D6192) services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.