Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. The Plan denied your request. The Plan says the
Medicare coverage criteria were not met. 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. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section.
Whether or not an IRF admission would be beneficial for the enrollee is not of issue.

Enrollees must meet the required criteria for coverage prior to admission. Based on the medical records
provided, at the time of the appeal, the enrollee did not require daily skilled therapy or daily skilling nursing
services at an IRF inpatient level of care. Medicare coverage criteria were not met. Therefore, we decided that
the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and
services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. 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. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section.

Based on the medical records provided, at the time of the appeal, you did not require daily skilled nursing or
daily skilled therapy at an IRF level of care. Whether or not the care would be beneficial is not of issue. You
must meet the required Medicare criteria for coverage for be approved. Therefore, we decided that the Plan
does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 3, 
2023. 
 
You asked the Plan to pay for procedure code 70450. You say that you believe that the charges are appropriate 
for the level of acuity and intensity of the quality medical services provided. The Plan denied your request. The 
Plan says this code is included in the skilled nursing facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 70450 has a Professional/Technical indicator of 1. This means that CPT code 70450 has 
both a professional and technical component. In this case, CPT code 70450 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 70450 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 70450 billed for date of service February 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a knee arthroplasty provided on May 23, 
2023. 
 
You asked the Plan to waive the cost share for a knee arthroplasty. You say that you disagree with the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $525 deductible which applies to outpatient surgery including 
services provided at hospital outpatient facilities.  Your contract with the Plan clearly says that you must pay 
10% coinsurance for each in-network Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay $41.86, which satisfied the $525 deductible for the knee arthroplasty. The 
remaining allowed amount is $13,235.61 ($13,235.61 - $41.86 deductible = $13,235.61). The item or service 
you asked the Plan to waive the deductible for falls within the outpatient surgery including services provided at 
hospital outpatient facilities benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $525 deductible which applies to outpatient surgery including services provided at 
hospital outpatient facilities. This cost sharing is a contractual obligation that had not been met at the time a 
knee arthroplasty was received on May 23, 2023.  
 
You have also been asked to pay $1,323.56, which is 10% coinsurance of the remaining allowed amount for the 
knee arthroplasty ($13,235.61 x 10% = $1,323.56). This item/service falls within the outpatient surgery 
including services provided at hospital outpatient facilities benefit category. The total amount you owe is 
$1,365.42 ($41.86 deductible + $1,323.56 coinsurance = $1,365.42). 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 
cost share for a knee arthroplasty provided on May 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft for spinal surgery (20930). 
 
You asked the Plan to pre-approve the service. You say that the requested service is a necessity for the 
enrollee's care. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Depuy vivigen allograft is experimental. More research is needed. Iliac crest autograft is the 
gold standard. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft for spinal surgery (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), expandable controller (E2377), and a harness for 
upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, and a harness. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 an electronic connection, expandable 
controller, and a harness. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has sufficient strength and 
function in upper extremities to manage standard power drives. 
 
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 electronic connection, expandable controller, and a harness have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), expandable controller (E2377), 
and a harness for upgrade to expandable controller (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an abutment 
supported to crown (D6058) for tooth #12 and #13. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs a bridge connected to 
implant because the old bridge broke off. The Plan denied your request. The Plan says the enrollee's benefit for 
the requested items or services has already been exhausted. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a prefabricated abutment (D6056) for tooth #10 and #11, an abutment supported 
to crown (D6058) for tooth #10 and #11 on October 31, 2023; therefore, the enrollee's benefit for the requested 
items or services was exhausted on the date of approval of October 31, 2023. Therefore, we decided that the 
Plan does not have to pre-approve a prefabricated abutment (D6056) and an abutment supported to crown 
(D6058) for tooth #12 and #13.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided from April 1, 2023, to April 30, 2023.

You asked the Plan to pay for SNF care. You say that services which the enrollee required and received during the period in question are coverable. The Plan denied your request. The Plan says the enrollee no longer required daily skilled services at an SNF level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found, based on the documentation provided, the enrollee no longer qualified for SNF care. The enrollee did not have documented skilled nursing and/or skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and could have been provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided from April 1, 2023, to April 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on June 20, 2023. 
 
You asked the Plan to pay for the refraction. You say that you are entitled to a yearly eye exam, and you want 
to be reimbursed. The Plan denied your request. The Plan says the provider is not a Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
refraction provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on April 14, 2023.

You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee.

The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the rules section of this letter are 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 pay for the definitive UDT for 15-21 drug classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that there is no documentation of early refills, self-escalation, use of drugs of abuse or diversion. The practice routinely sends urine toxicology for definitive testing. The testing was not 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 the definitive UDT for 15-21 drug classes have not been met. Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Respiratory PCR panel testing (87798 x12) provided 
June 13, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that your claim for Current Procedural 
Terminology (CPT) 87798 denied so you are appealing with medical records to prove medical necessity. The 
Plan denied your request. The Plan says this service is not medically necessary.  A respiratory pathogen panel 
test must not be unbundled and billed as individual components. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Respiratory PCR panel testing (87798 x12) provided June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0951, 
E0955, E0956, E1002, E1028, E2361, E2607, E2620, K0040, K0108, K0856, E1028, K0108, E1028, K0108, 
K0108, K0108). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 power mobility devices are covered when specific 
criteria are 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0951, E0955, 
E0956, E1002, E1028, E2361, E2607, E2620, K0040, K0108, K0856, E1028, K0108, E1028, K0108, K0108, 
K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided February 28, 2023, billed with 
codes 87640, 87481, 87798 X13, 87186 x12, and 87088. 
 
You asked the Plan to pay for the laboratory testing. You say that please reconsider this claim for payment. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. The urinalysis and urine culture have been approved. Based on this information, we decided that 
Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Urine PCR panel provided February 28, 2023, billed with codes 87640, 87481, 
87798 X13, 87186 x12, and 87088.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 home health aide visits and 18 skilled nursing visits.  

You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied home health services and that the services requested are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the health plan's denial should be upheld.  The requested number of home health 
skilled nursing visits is not shown 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 home health aide visits and 18 skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 (x4) billed for date of service June 2, 
2023.  
 
You asked the Plan to pay for procedure code 88374 (x4). You say that you would like the Plan to reconsider 
their denial of payment. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 (x4) have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 88374 (x4) billed for date of service June 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (81162, 81209, and 81218) provided on 
March 30, 2023. 
 
You asked the Plan to pay for procedure codes 81162, 81209, and 81218. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81162, 81209, and 81218 are not supported in the medical record. Specifically, a panel 
was performed and there is a more appropriate singular code for the services. 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 pay for the panel testing (81162, 81209, and 81218) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain or retainer crown (D6740) for teeth numbers 28 
and 31 provided on July 8, 2023. 
 
You asked the Plan to pay for a porcelain or retainer crown (D6740) for teeth numbers 28 and 31. You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 4, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for a porcelain or retainer crown (D6740) for 
teeth numbers 28 and 31  have not been met. Therefore, we decided that the Plan does not have to pay for a 
porcelain or retainer crown (D6740) for teeth numbers 28 and 31 provided on July 8, 2023.