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

 
We decided that the Plan does not have to pay for codes 22852, 20930, and 20936 billed for date of service 
December 27, 2022. 
 
You asked the Plan to pay for procedure codes 22852, 20930, and 20936. You say that you do not believe 
payment for these services should have been reduced. The Plan denied your request. The Plan says payment for 
code 22852 is bundled into payment for code 22844. The Plan also says that no separate payment is made for 
codes 20930 and 20936. 
 
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 22852 
is a column II code to column I code 22844. This claim has not been billed with an appropriate modifier to 
bypass the edit. As a result, code 22852 is not separately payable. 
 
Medical rules also say that the Physician Fee Schedule Status Indicator B means that payment for covered 
services is always bundled into payment for other services not specified. There will be no payment amounts for 
these codes and no separate payment is ever made.  In this case, codes 20930 and 20936 have a status indicator 
of B on the Physician Fee Schedule.  This means that no separate payment can be made for these codes. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 22852, 20930, and 20936 billed for date of service December 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
October 30, 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 this provider is a non-Medicare approved/certified 
freestanding emergency facility.  
 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 October 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99205 billed for date of service January 31, 2023. 
 
You asked the Plan to pay for the billed services. You say that the Plan forwarded the claim to the wrong 
provider. The Plan denied your request. The Plan says that benefits are not available under the plan. 
 
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 file shows the enrollee received an office visit for outpatient mental/behavioral health services. The 
enrollees plan benefit does include outpatient mental health services. There is no documentation or indication 
that the billing and rendering provider are not eligible to provide services under Medicare. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for procedure code 99205 billed for date of 
service January 31, 2023.  
 
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 services are medically necessary for you to return 
to your prior level of function. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an IRF. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous passive motion (CPM) device you rented 
from January 3, 2023, to January 29, 2023. 
 
You asked the Plan to pay for the CPM device. You say that you were told this item would be covered. The 
Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPM devices are only covered following knee 
replacement surgery.   
 
In this case, you had shoulder surgery, not knee replacement surgery.  Neither Medicare nor your Plan covers a 
CPN device following shoulder surgery. Please note that although you contend that you were told this item was 
covered, the company from which you rented this device had you sign a Member Liability Notice advising that 
this item would not be covered prior to dispensing you the device. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CPM device have not been met. Therefore, we decided that the Plan does not have to pay for 
the continuous passive motion (CPM) device you rented from January 3, 2023, to January 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services billed with code 81345 for December 
20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 the laboratory services billed with code 81345 for December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for  acupuncture treatments (97810, 97811) provided to the enrollee from February 25, 2022, through May 4, 2022.

You asked the Plan to pay for  these services. You say that these services should be covered by the Plan.  The Plan denied your request. The Plan says Medicare coverage criteria were 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 notes the providers are listed as doctors of Oriental Medicine. Medicare does not allow this type of provider to bill Medicare. Therefore, this claim could not be paid as billed. 

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made for services provided directly by a physician or practitioner who is not eligible to bill Medicare. 
The services at issue in this appeal were provided by doctors of Oriental Medicine and are not eligible to bill Medicare. Therefore, we decided that the Plan does not have to pay for  acupuncture treatments (97810, 97811) provided to the enrollee from February 25, 2022, through May 4, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that the documentation does not support that the member required daily skilled services which could only be delivered as an inpatient in a SNF.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF care. Our Medical Director states that the documentation does not support that it was medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" on an inpatient basis, in a skilled nursing facility setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary.  The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power operated vehicle (POV) 
(K0807). 
 You asked the Plan to pre-approve a group 2 heavy duty POV. The Plan denied your request. The Plan says 
this request does not meet criteria because there is no documentation that the scooter that was provided to you 
could not be repaired. 
 
The Plan follows Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a capped 
rental item may be replaced in cases of loss or irreparable damage. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 heavy duty POV. Our 
reviewer says that you do not meet the coverage criteria for the requested POV. Our physician reviewer found 
the documentation is conflicting that you have a mobility deficit. The nurse practitioner notes state you have 
normal gait and station. Our reviewer found that additionally, the documentation is not clear that if a gait 
abnormality significantly impairs mobility related activities of daily living in the home and cannot effectively 
be helped by a walker. The documentation does not reveal detailed evidence/proof of what happened to the 
prior POV and that it is damaged beyond repair. Our physician reviewer found that the prior scooter is less than 
5 years old, but the documentation is not clear on precise details of the scooter and whether the requested 
scooter is near identical to the prior scooter. Our reviewer also found that the approved physiatry evaluation has 
not been completed to indicate the medical necessity of this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 heavy duty POV have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 heavy duty power operated vehicle (POV) (K0807).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet radiofrequency ablation (RFA) (64636, 
64635). 
 
You asked the Plan to pre-approve lumbar facet RFA. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that  
an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is 
considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain (with the duration of relief being consistent with the agent used). 
 
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 lumbar facet RFA. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have had 
bilateral L3-5 medial branch block #1 on April 14, 2023, and reports greater than 80% relief for over 8 hours 
(and #2 on May 10, 2023 and reports the same relief.) However, her noted pain scales were not clearly 
documented to support the noted percentage of pain relief. This is also not evident for the noted previous 
radiofrequency ablation that was provided in 2019. Therefore, the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar facet RFA have not been met. Therefore, we decided that the Plan does 
not have to pre-approve lumbar facet radiofrequency ablation (RFA) (64636, 64635).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the continuation of Keytruda is not supported.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda. Our Medical Director states that there is insufficient documentation and support in the compendia/medical literature to support that continued coverage of Keytruda beyond 24 months was medically reasonable and necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of Keytruda.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on March 3, 2023, billed with 
code 73630. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code assigned shall be 
the setting in which the beneficiary received the service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The file shows that the enrollee was an 
inpatient on the date of service. As such, the outpatient POS code 22 is not appropriate. Therefore, we decided 
that the Plan does not have to pay for radiological services provided on March 3, 2023, billed with code 73630.
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 you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, IRF care is 
not considered medically reasonable or necessary.  
 
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. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal cancer screening (G0121) ringers lactate 
infusion (J7120) injection, propofol (J2704) injection, lidocaine HCl (J2001) and anesthesia for lower intestinal 
endoscopic procedures (00812) provided September 24, 2021. 
 
You asked the Plan to pay for the procedure. You say that you billed the claim timely in good faith to 
traditional Medicare. Therefore, you are requesting the Plan to reconsider payment. The Plan denied your 
request. The Plan says the claim was received after the timely filing limitation. 
 
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 procedure was not filed until October 12, 2022. 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 colorectal cancer screening (G0121) ringers lactate infusion (J7120) injection, propofol (J2704) injection, lidocaine HCl (J2001) and anesthesia for lower intestinal endoscopic 
procedures (00812) provided September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on October 13, 2022.

You asked the Plan to pay for  these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested service had already been exhausted. Maximus overturned the Plans denial for insufficient information in the case file showing this benefit was exhausted. The Plan requested a reopen and submitted the required information. 

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 in excess of Medicare coverage, the record shows your benefit for this service was exhausted on October 6, 2022. Therefore, we decided that the Plan does not have to pay for  the comprehensive oral evaluation (D0150) provided on October 13, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency services provided on October 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare is creating additional flexibilities to 
allow licensed independent freestanding emergency departments (EDs) to participate in Medicare and 
Medicaid to help address the urgent need to increase hospital capacity to provide care to patients.  
 
We looked at the file and Medicare rules. The services in this case were provided during the COVID-19 
emergency period, during which freestanding emergency departments (EDs) were allowed participate in 
Medicare to help address the urgent need to increase hospital capacity to provide care to patients. Based on this 
information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided 
that the Plan has to pay for the emergency services provided on October 28, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 9, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes D72.821 and 
D46.9. Diagnosis code D72.821 has an Excludes1 note and cannot be billed with diagnosis code D46.9. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on February 9, 2023.