Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. 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 clinical 
documentation shows that the amount/frequency of total home health skilled nursing visits requested (3 times 
per week for a total of 17 visits) is appropriate as there is active monitoring for the need of further 
chemical/physical debridement of left ischial wound (in an enrollee with paraplegia and impaired sensation). 
Thus, the records do show that 10 additional home health skilled nursing visits are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition 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 been met. Therefore, we decided that the Plan has to 
pre-approve 10 home health skilled nursing 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service September 
15, 2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code is 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. 
 
We find that CPT code 99223 is not supported in the medical record. The records show that the enrollee was 
seen for a right hip fracture. Imaging was provided and surgery was scheduled. The records do not support a 
high level of decision making. Based on this information, we decided that Medicare rules for coverage of the 
billed service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99223 billed for date of service September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injection at the additional level (64495) 
provided on August 9, 2023. 
 
You asked the Plan to pay for the facet joint injection at the additional level (64495). You say that you are 
requesting reconsideration based on medical necessity. The Plan denied your request. The Plan says the 
provider did not provide evidence of unique circumstances for a third level to be approved. 
 
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 facet joint injection at the additional 
level (64494). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee does not meet the LCD coverage indications 
for a three or four-level facet joint procedure. 
 
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 facet joint injection at the additional level (64495) have not been met. 
Therefore, we decided that the Plan does not have to pay for the facet joint injection at the additional level 
(64495) provided on August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E0466 ventilator for the enrollee.

You asked the Plan to provide coverage for this device. You say that this device is medically necessary. The
Plan denied your request. The Plan says the Medicare criteria are not met. Maximus partially overturned the
Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that ventilators may be
covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive
diseases, and chronic respiratory failure due to COPD. Claims for ventilators used to provide CPAP or bi-level
CPAP therapy will be denied as not 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 pre-approve continuation of the ventilator. Our
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's
respiratory needs could be met with BiPAP with average volume-assured pressure support (AVAPS), with a
backup rate. The records do not show that this has been tried and failed as an outpatient. Medicare does not
cover a home ventilator when used at settings that can be provided with BiPAP. Medicare coverage criteria
were not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of the ventilator have not been met. It has also been determined the
3-month partial approval for transition was done so in error. Therefore, we decided that the Plan does not have
to provide coverage for an E0466 ventilator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0427-RW) provided to the enrollee on
October 24, 2022.

You asked the Plan to pay for this claim as billed. You say that 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
stated that Maximus did not apply the correct billing criteria. The Plan demonstrated that this claim denied
because this service was billed with an inappropriate modifier. This service was billed with a Modifier RW
which is not an appropriate destination modifier for use with ET3 ambulance claims. The Medicare Claims
Processing Manual - Chapter 15 - Ambulance - Section 30 - General Billing Guidelines - A) Modifiers specific
to Ambulance Service Claims explains how ambulance services should be billed and what modifiers should be
used. The Medicare Benefit Policy Manual Chapter 10 - Section 10 explains that the Medicare ambulance
benefit is a transportation benefit and without a transport there is no payable service. When multiple ground
and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance
provider/supplier that actually furnishes the transport. The Plan shows that modifier "W" is an inappropriate
destination modifier for use with ET3 ambulance claims. It does not apply to Medicare Advantage plans. Only
to Private-Fee-For-Service (PFFS) MA Plans. Therefore, the Medicare billing criteria were not met.

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 omission of an
appropriate modifier based on the Plan contract type. Medicare rules for coverage of this claim as billed have
not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0427-RW)
provided to the enrollee on October 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen or methane test (91065). 
 
You asked the Plan to pre-approve the diagnostic test. You say that this breath test will give your doctor 
information to help you treat what is happening. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth (SIBO) and measuring small bowel transit time is not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic test have not been met. Therefore, we decided that the Plan does not have to pre-
approve a breath hydrogen or methane test (91065).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G7 sensors and receivers. 
 
You asked the Plan to pre-approve the Dexcom G7 supplies. You say that the medical records provided support 
the need for the requested CGM. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  Plans must ensure that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, 
the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use 
of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic test strips or monitors. Therefore, we decided that the Plan does not have to pre-approve Dexcom 
G7 sensors and receivers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311), and a transit option (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection, and a 
transit option. You say that the requested items are a medical necessity for the enrollee. The Plan denied your 
request. The Plan says the requested items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 expandable controller with harness 
and electronic connection. Our reviewer says that an expandable controller with harness and electronic 
connection is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has adequate strength 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 expandable controller with harness and electronic connection have not been 
met. The transit option at issue in this appeal does not serve a purpose that is primarily medical in nature. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311), and a transit option (K0108) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the prior authorization form from the enrollees provider 
indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 26, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with removal of polyps 
provided on August 03, 2023. 
 
You asked the Plan to waive the copayment for a colonoscopy with removal of polyps. You say that you have 
never had to pay for a colonoscopy. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for all other services including diagnostic colonoscopy performed at an ambulatory surgical center. 
 
You have been asked to pay a $250 copayment for a colonoscopy with removal of polyps. This item/service falls within the all other services including diagnostic colonoscopy performed at an ambulatory surgical center 
benefit category. 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 copayment for a colonoscopy with removal of 
polyps provided on August 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058) provided on February 9, 2023, and August 3, 2023. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that you were told that having a crown on an implant did not make a difference. The Plan 
denied your request. The Plan says these services are not covered under your plan. 
 
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 or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on 
February 9, 2023, and August 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Gene Panel (0345U) provided 
on July 13, 2023. 
 
You asked the Plan to pay for the GeneSight Psychotropic Gene Panel (0345U). You say that the GeneSight 
Psychotropic Gene Panel (0345U) testing was medically necessary. The Plan denied your request. The Plan 
says the enrollee did not meet criteria for the provided GeneSight Psychotropic Gene Panel (0345U) testing. 
 
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 the GeneSight Psychotropic Gene Panel 
(0345U). Our reviewer says that the enrollee did not meet criteria for the provided GeneSight Psychotropic 
Gene Panel (0345U) testing. Our physician reviewer found the enrollee suffers from Major depressive disorder, 
recurrent, moderate (F33.1), anxiety disorder (F41.3) and Bipolar Disorder, Current Episode Mixed, Moderate 
(F31.62). Based on review of the records provided there is no documentation of failed medication trial. 
Therefore, the medication has not been found to be useful in assistance with the enrollees symptoms. The 
Medicare LCD L38394 requires the patient to be tried on at least one medication. The ordering psychiatrist 
must be board certified in psychiatry or neuropsychiatry. Documentation does not show the improvement with 
the medication as the medication was not found to be useful. Utilizing the information from Medicare LCD 
L38394, this enrollee does not meet the criteria for GeneSight Psychotropic Assay. 
 
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 GeneSight Psychotropic Gene Panel (0345U) have not been met. Therefore, 
we decided that the Plan does not have to pay for the GeneSight Psychotropic Gene Panel (0345U) provided on 
July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain crown (D2750) and core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says dental services from an out-of-network provider are not covered 
by your supplemental benefits.  
 
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. 
 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve porcelain 
crown (D2750) and core buildup (D2950).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 8, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634 and 87502 billed for date of service 
April 4, 2023. You asked the Plan to pay for the billed services. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 87634 and 87502 are not supported in the medical record. In this case, an order form 
was not included in the documentation to show what tests were requested by the provider. There were also no 
medical records other than the lab results to show the physicians intent for the tests to be performed. 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 procedure codes 87634 and 87502 billed for date 
of service April 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone density study provided on October 13, 2023. 
 
You asked the Plan to pay for a bone density study. You say that prior authorization was not required. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 bone density study provided on October 13, 2023.