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

 
We decided that the Plan does not have to pre-approve the Infuse BMP allograft (20930). 
 
You asked the Plan to pre-approve the Infuse BMP allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Infuse BMP Allograft in the 
setting of posterior lumbar spine fusion surgery with the Globus Sable expandable cage have not been 
demonstrated in the peer-reviewed literature. 
 
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 Infuse BMP allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Infuse BMP allograft is not approved for use in the posterior spine. It is 
experimental. 
 
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 Infuse BMP allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Infuse BMP allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implant for tooth number 18 (D6010), an abutment supported porcelain/ceramic crown for tooth number 18 
(D6058), and a custom fabricated abutment-includes placement for tooth number 18 (D6057). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested items/services are not covered 
under the supplemental dental policy.  
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of an implant body: endosteal implant for tooth number 18 (D6010), an abutment supported 
porcelain/ceramic crown for tooth number 18 (D6058), and a custom fabricated abutment-includes placement 
for tooth number 18 (D6057).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 81321 and 81351 provided on 
April 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's 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 lab services billed with codes 81321 and 81351 provided on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infections agent detection by nucleic acid (87798) provided 
April 24, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration and 
payment in full for the molecular PCR test performed  The Plan denied your request. The Plan says the 
documentation does not support 13 units tested. Only 10 units of infectious agents are supported in the 
documentation.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We asked our coder 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 laboratory service. Our reviewer says that the records do 
not support that the criteria has been met for the billed service. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The procedure code represents "not otherwise specified". 
The laboratory report does not include documentation of tests being reported with CPT 87798. Therefore, the 
procedure code and units billed cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for infections agent detection by nucleic acid (87798) provided April 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from 
November 4, 2022, to March 30, 2023. 
 
You asked the Plan to pay for the inpatient psychiatric hospital services. You say that you have provided 
medical records to support payment. The Plan denied your request. The Plan says the patient has exceeded their 
190 lifetime days for inpatient psychiatric hospital care. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for more than a total 
of 190 days of inpatient psychiatric hospital services during the patient's lifetime.   
In this case, records so that payment has already been made for 190 days of inpatient psychiatric hospital care 
for this patient.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient psychiatric hospital services provided from November 4, 2022, to March 30, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service May 26, 
2023. 
 
You asked the Plan to pay for procedure code G0452. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code G0452 is bundled into 
payment for code 81301. 
 
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 G0452 is a column II code to column I code 81301. Code G0452 was 
billed with the -59 modifier. The medical records do not show that the service billed with the -59 modifier was 
a distinct procedural service. 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 G0452 billed for date of service 
May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 for date of service May 26, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism 
 
We find that CPT code 87798 is not supported as billed in the medical record. Specifically Review of the file 
shows that 13 units of this code were billed; however, the documentation only supports 10 units of infectious 
agents. Based on this information, we decided that Medicare rules for coverage of procedure code 87798 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87798 for date of 
service May 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95938 and 95955 billed for date of service 
February 11, 2022.  
 
You asked the Plan to pay for procedure codes 95938 and 95955. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that if a code has an MUE that is adjudicated as a 
claim line edit, (i.e., MAI equal to 1) appropriate use of CPT modifiers (i.e., 59 or -X{EPSU}, 76, 77, 91, 
anatomic) may be used to report the same HCPCS/CPT code on separate lines of a claim. 
 
In this case CPT codes 95938 and 95955 were billed with modifiers 26 and 77. Modifier 77 is used when a 
repeat procedure or service is provided by another physician or other qualified healthcare professional. No 
additional providers have billed the health plan for codes 95938 and 95955 on this date or any other date. This 
indicates that the use of modifier 77 was used incorrectly. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95938 and 95955 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 95938 and 95955 billed for date of service February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay procedure code 81345 billed for date of service April 3, 2023. 
 
You asked the Plan to pay procedure code 81345. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for 
code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 procedure code 81345 billed for date of service April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for crowns (D2751), prefabricated post and core
(D2954), pontic (D6241), and extraction (D7140) for teeth #8, #9, #10, #12, #13, #14, #28, and #29.

You asked the Plan to provide coverage for these services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services are not covered.

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. The previous determination stated that the Plan must pre-approve the services because they
did not provide a 2023 Evidence of Coverage (EOC) to support that the services are not covered by the
supplemental dental benefit. The Plan has since submitted the correct EOC, and the documentation now
supports that the services are not covered by your supplemental benefit or Medicare benefit.

Therefore, we decided that the Plan does not have to provide coverage for crowns (D2751), prefabricated post
and core (D2954), pontic (D6241), and extraction (D7140) for teeth #8, #9, #10, #12, #13, #14, #28, and #29.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for chiropractic services provided on November 22,
2021, and November 23, 2021.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says your request was
filed on March 22, 2023, which is past the timely filing date. Maximus overturned the Plans denial. The Plan
requested a reopen and confirmed the date of your request was past the filing limit.

The Plan is correct in this case. The Plan follows Medicare rules. The rules say that claims for services must be
filed no later than one calendar year after the date of service. The Plan contract clearly states claims for
payment must be filed one year from the date of service. You did not file this claim within a year of the dates
of service. Therefore, we decided that the Plan does not have to pay for to pay for chiropractic services
provided on November 22, 2021, and November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the implantation of an intrathecal pain pump
for the enrollee.

You asked the Plan to provide coverage for the implantation of an intrathecal pain pump. The Plan denied your
request. The Plan says the Medicare coverage criteria are not met because the enrollee already has a spinal cord
stimulator in place. Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus
did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say implantation of an
infusion pump is contraindicated when other implanted programmable devices are present as crosstalk between
devices may inadvertently change the prescription. The medical records show the enrollee has an implanted
spinal cord stimulator. This means implantation of an intrathecal pain pump would be contraindicated.
Therefore, we decided that the Plan does not have to provide coverage for the implantation of an intrathecal
pain pump for the enrollee.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the enrollee does
not meet criteria for IRF care.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that the documentation does not sufficiently support that complexity of the enrollee's
nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The enrollee's medical problems were stable, and there were no identified 
problems that needed inpatient medical management. There were no complex nursing or rehabilitation needs.
Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Heelex radiation for plantar fascial
fibromatosis.

You asked the Plan to provide coverage for Heelex radiation. The Plan denied your request. The Plan says this
treatment is not covered for the enrollee's condition. Maximus overturned the Plans denial. The Plan requested
a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The documentation is insufficient to support that
Heelex low-dose radiation therapy is medically reasonable and necessary for this condition. While it may be
beneficial, there are more existing and available medically appropriate alternative treatments for the enrollee's
condition. Further investigation into the potential role in the treatment of osteoarthritis with modern low-dose
radiation therapy is recommended prior to its approval by Medicare. Based on this information, we decided that
Medicare rules for coverage of Heelex radiation have not been met. Therefore, we decided that the Plan does
not have to provide coverage for Heelex radiation for plantar fascial fibromatosis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a computed tomography scan with calcium
scoring for the enrollee.

You asked the Plan to provide coverage for calcium scoring. The Plan denied your request. The Plan says
calcium scoring is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria as calcium scoring is a screening.

The Plan follows Medicare rules. Quantitative calcium scoring is not a covered service and will be denied as
not medically necessary. Calcium scoring reported in isolation is considered a screening service. When
performed in association with CT angiography, there is neither separate nor additional included reimbursement
for the calcium scoring. The test at issue in this appeal, calcium scoring, is being requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to provide coverage for a computed tomography scan with calcium scoring for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shank foot system with vertical loading pylon (L5987)
and axial rotation unit (L5984) for the enrollee.

You asked the Plan to pre-approve a shank foot system with vertical loading pylon and axial rotation unit. You
say that the items are medically necessary. The Plan denied your request. The Plan says that the items are not
medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a shank foot
system with vertical loading pylon and axial rotation unit. Our Medical Director states that the enrollee
previously underwent a transtibial amputation. The prior prosthesis was reportedly ill-fitting and resulted in a
wound in the distal aspect of his residual limb. A new prosthesis with a K3 foot was requested. The clinical
note documents that the enrollee's stump had shrinkage and was without redness or areas of concern. The
clinical documentation is insufficient to support that the requested vertical loading pylon and axial rotation unit
were medically necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition
does not meet criteria for coverage of a shank foot system with vertical loading pylon and axial rotation unit.

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 shank foot system with vertical loading pylon and axial rotation unit have not
been met. Therefore, we decided that the Plan does not have to pre-approve a shank foot system with vertical
loading pylon (L5987) and axial rotation unit (L5984) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for an additional unit of code 64488 provided on February 9,
2023.

You asked the Plan to pay for the additional unit of code 64488. The Plan denied your request. The Plan says
the additional unit exceeds the units allowed to be billed. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that per
the National Correct Coding Initiative (NCCI) manual, Chapter 8, only one unit of CPT 64488 should be
reported per date of service for a single enrollee encounter.

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, the Plan provided documentation to show the billing guidelines do not
allow more than one unit of code 64488 to be reported an enrollee on a given date of service. Medicare rules
for coverage of the additional unit have not been met. Therefore, we decided that the Plan does not have to pay
for an additional unit of procedure code 64488 rendered on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and
electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that
the enhanced electronics are needed due to the inability to press and hold the buttons on a standard joystick.
The Plan denied your request. The Plan says that the records do not show a medical need to control the
wheelchair's power options through a joystick.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness and electronic connection. Our Medical Director states that clinical documentation does not
support that an expandable controller, harness, and electronic connection are medically necessary for this
enrollee to control the power options through a joystick. Our Medical Director found that the enrollee's
condition does not meet criteria for coverage of an expandable controller, harness and electronic connection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller, harness and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness
(E2313) and electronic connection (E2311) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87505) provided to the enrollee on September
5, 2022.

You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your
request. The Plan says you billed with an incorrect place of service on the claim. Maximus overturned the Plans
denial for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity issue
but the fact that the claim was submitted with an error.

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 (87505) provided to the enrollee on September 5, 2022.