Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93040 billed for date of service March 3, 
2023. 
 
You asked the Plan to pay for procedure code 93040. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93040 is bundled into payment for code 
93306. 
 
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 93040 
is a column II code to column I code 93306. 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 93040 billed for date of service March 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) home health physical therapy (PT) visits 
(G0151 x5).  
 
You asked the Plan to pre-approve home health services. You say that you still need PT as you have difficulty 
walking and you cannot travel to an outside physical therapist.  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 the clinical 
documentation shows that you are ambulating greater than 200 feet with assistive device and does not show 
that you are home bound; thus, the records do not show that 5 additional physical therapy skilled therapy 
sessions would be required in home setting to effectively provide treatment, care, and/or services in order to 
improve your level of function, or to establish/perform a maintenance program to maintain your level of 
function and/or prevent deterioration. 
 
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 five (5) home health physical therapy (PT) visits (G0151 x5).
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 enrollee requires acute inpatient rehabilitation, as 
opposed to other levels of care. The Plan denied your request. The Plan says based on the available 
information, admission to IRF is not reasonable and necessary, as the member's condition does not meet these 
Medicare requirements. Services needed may be provided safely in a lower level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 pre-approve an electronic connection (E2311), expandable controller 
(E2377), expandable controller harness (E2313), and joystick armor (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, expandable controller 
harness, and joystick armor. 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, expandable controller harness, and joystick armor. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found provided records document that the enrollee has 4/5 right hand grasp strength and 4/5 right hand range of 
motion thus indicating she has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. As the accessories to control the chair's power functions through a 
joystick do not meet criteria for coverage, the joystick armor (K0108) is not covered. 
 
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, expandable controller harness, 
and joystick armor have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection (E2311), expandable controller (E2377), expandable controller harness (E2313), and 
joystick armor (K0108).
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 would like to go to an inpatient rehabilitation, 
instead of a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's condition does 
not meet the Medicare rules for an IRF admission. 
 
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, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high-dose electronic brachytherapy. 
 
You asked the Plan to pre-approve the requested services. You say that this allows radiation to be delivered 
over a shorter period of time. The Plan denied your request. The Plan says this type of superficial radiation 
treatment is insufficient for the enrollee's condition.  
 
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 requested services. Our physician 
reviewer found that radiation is a standard approach to the treatment of skin cancer and is often preferred over 
surgery when resection is likely to result in unacceptable morbidity or cosmesis. Many factors determine which 
of many treatments are best suited for an individual patient, including histology, size, depth, location, and 
comorbidities.  The most recent National Comprehensive Cancer Network (NCCN) guidelines for basal cell and squamous cell 
skin cancers explicitly state that there are insufficient long-term efficacy and safety data to support routine use 
of electronic surface brachytherapy. For this case, there are no compelling reasons offered for why SRT would 
be needed over more standard approaches of radiation delivery. Therefore, the request is not medically 
reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve high-dose electronic brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (CMT) provided 
from August 10, 2022, to May 31, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment (CMT). You say that you have been 
taking care of the enrollee on and off for over 30 years. The Plan denied your request. The Plan says enrollees 
must get their care from network providers. 

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (CMT) 
provided from August 10, 2022, to May 31, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 27, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided the DEX Diagnostic Registry page that shows code 81479 is not listed as a recommended code for DEX-Z code ZB1CW.
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, this claim was not billed with the appropriate codes for this testing. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing identified with code 0241U for date of service 
December 9, 2022. 
 
You asked the Plan to pay for the testing identified with code 0241U. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing identified 
with code 0241U have not been met. Therefore, we decided that the Plan does not have to pay for the testing 
identified with code 0241U for date of service December 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion therapy services provided on January 30, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the infusion therapy services. You say that this is supported in the records. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the infusion therapy services provided on January 
30, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 19, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturn the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan notes that while
the claim was billed with a valid DEX Z-Code of ZB1CW, procedure code 81479, defined as unlisted
molecular pathology, is not the recommended code for the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code. In this case, this claim was not paid as billed as code
81479 is not the recommended code for the unique identifier code billed. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided
to the enrollee on May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator, electronic shock unit provided 
on March 27, 2023. 
 
You asked the Plan to pay for a neuromuscular stimulator, electronic shock unit. You say that this was 
medically necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a neuromuscular 
stimulator, electronic shock unit provided on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device 
supplies. 
 
You asked the Plan to pre-approve CPAP supplies. You say that the requested supplies are a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage for the requested supplies have not 
been met.  
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires that 
symptoms of obstructive sleep apnea are improved and objective evidence of adherence to use of the PAP 
device is provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CPAP supplies have not been met. Specifically, the case record does not support that you are 
adhering to use of your CPAP device. Therefore, we decided that the Plan does not have to pre-approve 
continuous positive airway pressure (CPAP) device supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7261) and the 
collection application of a blood concentrate (D7921) provided on May 10, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the primary 
closure of a sinus perforation (D7261) and the collection application of a blood concentrate (D7921) provided 
on May 10, 2023.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies provided to the enrollee on September 26, 2022.
You asked the Plan to pay for this claim. You say that these supplies should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing 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 that the claim history claims have been submitted for these supplies indicating the equipment is a rental item. Medicare guidelines state that" During the rental of a TENS unit, supplies for the unit are included in the rental allowance; there is no additional allowance for items such as electrodes, lead wires, and batteries". Since the provider is renting the TENS Unit to the member the provider should not bill for supplies as stated in the LCD A52520. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). Per Article L33802-Separate allowance will be made for replacement supplies when they are reasonable and necessary and are used with a covered TENS. The usual maximum utilization is: - 2 TENS leads - a maximum of one unit of A4595 per month. - 4 TENS leads - a maximum of two units of A4595 per month.
The claim was submitted for 6 units of A4595. The same claim shows the provider is billing for a rental of the TENS unit.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to the rules regarding supplies for rented equipment and for billing in excess of the units allowed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies provided to the enrollee on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain crown (D2750) provided on February 21, 2023. 
 
You asked the Plan to pay for a porcelain crown (D2750). You say that this provider is an in-network provider. 
The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
porcelain crown (D2750) provided on February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the planned procedure listed under CPT code 23472 is not listed on the 
CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.