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

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 18, 2022, and billed under code 72125-QQ.
You asked the Plan to pay for these services. You say that this claim should be paid as billed. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned stated the records support the necessity of the services billed. The Plan requested a reopen and stated the issue was not medical necessity but the payment of the code. The Plan notes this is a payment dispute for how the services were calculated. The Plan made payment following Medicare guidelines for Composite APCs. The payment of Line 2 of the claim for code 72125 - QQ for computed tomography of the neck and spine without dye is included in the payment of Line 1 for code 70450 - QQ for computed tomography of the head and brain without dye. The Plan notes that based on Medicare Claims Processing Manual 10.2.1 - Composite APCs (Rev. 3941; Issued: 12-22-17; Effective: 01- 01-18; Implementation: 01-02-18), Composite APCs provide a single payment for a comprehensive diagnostic and/or treatment service that is defined, for purposes of the APC, as a service typically reported with multiple codes.
When codes that meet the criteria for payment of the composite APC are billed on the same date of service, Medicare makes a single payment for all of the codes as a whole, rather than paying individually for each code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, code 72125 could not be paid due to its billing relationship to 70450. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 18, 2022, and billed under code 72125-QQ.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 00731-QX billed for date of service November 17, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the reports support the level of service. The Plan 
denied your request. The Plan says that the claim line has been previously processed. 
 
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. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The case file does not include documentation such as 
an additional claim or an explanation of benefits to show that the service at issue was previously billed. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Based on this information, we decided that Medicare rules for coverage have 
been met. Therefore, we decided that the Plan has to pay for procedure code 00731-QX billed for date of 
service November 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says records do not show that the 
enrollee has had an initial treatment with the requested device to show that she can comfortably place the 
device and that she had improvement in her measurements. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The records show that you had reduction in lower extremity swelling and venous insufficiency wound size with 
conservative therapy. Objective measurements were not included to demonstrate the extent of improvement 
with conservative therapy. The records also do not show that the enrollee had an initial treatment with the 
requested device. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression 
device (E0651) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a thoracic epidural steroid injection. 
 
You asked the Plan to pre-approve a thoracic epidural steroid injection. You say that a thoracic epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says that the requested thoracic 
epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 thoracic epidural steroid injection. 
Our reviewer says that the requested thoracic epidural steroid injection is considered medically necessary. Our 
physician reviewer found that the enrollee has upper back, neck, and right shoulder pain. The enrollee has the 
diagnoses of cervical and brachial radiculopathy, myofascial pain, myositis, cervicalgia, cervical spinal 
stenosis, and cervical spondylosis. The cervical computerized tomography (CT) imaging on January 27, 2023, 
revealed C5-6 disc height narrowing and osteophyte formation. The cervical magnetic resonance imaging 
(MRI) on May 12, 2021, revealed C2-3 mild disc bulge, facet arthropathy, mild spinal canal narrowing, and 
mild left foraminal narrowing; C3-4 disc bulge, facet arthropathy, moderate to severe spinal canal stenosis, and 
moderate to severe bilateral foraminal stenosis; C4-5 mild disc bulge, facet arthropathy, moderate canal stenosis, and moderate bilateral foraminal stenosis; C5-6 mild right facet arthropathy, moderate to severe canal 
stenosis, and moderate to severe bilateral foraminal stenosis; C6-7 mild disc bulge, mild canal narrowing, and 
mild right foraminal narrowing; and C7-T1 slight disc bulge. The standard approach to performing a cervical 
epidural is to go at C7-T1 or T1-T2. This is because of anatomic issues at the higher levels. The request is 
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 a thoracic epidural steroid injection have been met. Therefore, we decided that 
the Plan has to pre-approve a thoracic epidural steroid injection.  
 
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: Favorable

 
We decided that the Plan has to pre-approve the repair of complex retinal detachment with vitrectomy and 
membrane peeling with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the repair of a complex retinal detachment surgery with an OON provider. 
You say that the doctor you need to see only has privileges at the OON hospital. The Plan denied your request. 
The Plan says that the procedure can be performed by a network provider. 
 
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. Specifically, the Plan did not provide us with the names of any available in-
network surgeons who are able to perform the surgery being requested. We reached out to the Plan to obtain 
the names of in-network surgeons who were available and able to provide the repair of complex retinal 
detachment with vitrectomy and membrane peeling but were not provided with any names. Without this 
necessary information, we are not able to review whether the Plans denial is medically justified on the basis 
that it is offering adequate care to meet the enrollees medical needs. Therefore, we decided that the Plan has to 
pre-approve the repair of complex retinal detachment with vitrectomy and membrane peeling with an out-of-
network (OON) provider.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Padcev. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of Keytruda and Padcev is not 
approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. The combination is not used 
as a first line therapy with progression on Keytruda. The use is not supported by the major drug compendia or clinical research that appears in a Medicare-approved medical journal. The requested drugs are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda and Padcev.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the acupuncture services provided to the enrollee from April 26, 2022, to May 18, 2022.
You asked the Plan to pay for the acupuncture services. You say that this was medically necessary. The Plan denied your request. The Plan says that that the claims submitted do not follow Medicare coding guidelines for chronic low back pain. Maximus overturned the Plan's denial. The Plan requested a reopening and stated we did not apply the correct criteria.
In this case this claim cannot be paid as billed as acupuncture is not covered for a diagnosis of lumbago with sciatica (unspecified side). Therefore, we decided that the Plan has to pay for the acupuncture services provided to the enrollee from April 26, 2022, to May 18, 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: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on January 21, 2022 and billed under code 10140-AS-59-RT.

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 were not met. Maximus partially overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information regarding the overturned code.

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, you billed assistant surgery services for code 10140. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Medicare coverage criteria for the incision and drainage services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance code A0425 billed for date of service July 31, 
2022. 
 You asked the Plan to pay for the billed services. You say that the enrollee was transferred to a higher level of 
care. The Plan denied your request. The Plan says the billed units exceeded the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 299 units of 
this code, exceeding the MUE. 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 ambulance code 
A0425 billed for date of service July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vision supply warranty charge (V2797) provided on 
February 2, 2023.  
You asked the Plan to pay for a vision supply warranty charge. You say that you were told this would be 
covered. The Plan denied your request. The Plan says this is not covered under your benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 routine eye exam every year and up to $200 for eyeglasses or contact lenses. 
 
We looked at the file and the Plan's rules. Warranty charges are not covered under the Plans vision benefit. 
Based on this information, we decided that the Plan's rules for coverage of a vision supply warranty charge 
have not been met. Therefore, we decided that the Plan does not have to pay for a vision supply warranty 
charge (V2797) provided on February 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the scan is necessary to properly diagnose the 
enrollee to ensure that the correct treatment method is used. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that in this case the enrollee is not noted 
to meet the diagnostic criteria for both Alzheimers disease and frontotemporal dementia as required by the 
NCD. The service would not meet the Medicare criteria for coverage. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for code 87640.
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 requested a reopen and confirmed the outcome of codes 87150, 87481, 87500, 87641, 87651, 87653, 87798 and 87801 were settled under a separate appeal.
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 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. 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 87640.
As stated above codes 87150, 87481, 87500, 87641, 87651, 87653, 87798 and 87801 billed for date of service July 22, 2022, were handled under a separate case file.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Resolve MDx urine PCR (polymerase chain reaction) testing 
provided on January 17, 2023. 
 
You asked the Plan to pay for Resolve MDx urine PCR testing. You say that this test was medically necessary 
and appropriate. The Plan denied your request. The Plan says this test is not medically necessary and is not 
considered the standard of care. 
 
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 pay for Resolve MDx urine PCR testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no evidence the enrollee had a urinary tract infection which 
required treatment. This testing was not 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 Resolve MDx urine PCR testing have not been met. Therefore, we decided that 
the Plan does not have to pay for Resolve MDx urine PCR (polymerase chain reaction) testing provided on 
January 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) supplies or 
accessories (A9999 x2) and drug (J3490) provided on November 30, 2022, and December 5, 2022. 
 
You asked the Plan to pay for the DME and drug. You say that this treatment in its entirety was for your 
confirmed diagnosis of COVID-19. You also say that by law, this treatment is to be covered under your 
insurance plan in its entirety. The Plan denied your request. The Plan says the services received are not covered 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the DME and drug. Our reviewer says that 
these services were not medically reasonable and necessary. Our physician reviewer found the injected 
ingredients are not proven with high quality studies to show improvement in COVID-19 patient's symptoms 
and infection status to support this request. Also, the provided documentation did not objectively show a 
deficiency in any of the nutrients in the formulas or failure of oral administration to justify this treatment or any 
other reason. Our reviewer found that therefore, without sufficient support made, the request for the DME and 
drug will be considered not medically necessary, nor would they be considered safe or effective based on lack 
of evidence for such. 
 
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 DME and drug have not been met. Therefore, we decided that the Plan does 
not have to pay for the durable medical equipment (DME) supplies or accessories (A9999 x2) and drug (J3490) 
provided on November 30, 2022, and December 5, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 11 home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says that 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 medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation shows that not all appropriate treatment goals have been met. There is also mention of goals to 
advance with assistive devices thus the professional skill of a physical therapist would be required to meet 
documented goals. The enrollee is beneath previous baseline of mod I and is home bound thus the records do 
show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's level of function. 11 home health physical therapy visits are medically necessary based 
on the clinical documentation. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve 11 home health physical therapy visits.  
 
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.