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

We decided that the Plan does not have to pay for the gene panel testing billed for date of service November 7, 2022.

You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. The Plan denied your request. The Plan says the rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and the rules. We find  the panel testing was not billed with a single code ass required. We also find that this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 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 the gene panel testing billed for date of service November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology office visit provided from January 09, 2023, 
to January 31, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a dermatology office visit. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 
item/service 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 a dermatology office visit provided from January 
09, 2023, to January 31, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) setup fees (A9901), 
segmental gradient pressure pneumatic appliance (E0673), neuromuscular stimulator (E0745), and electrical 
stimulator supplies (A4595) provided on October 29, 2021. 
 You asked the Plan to pay for the DME setup fees, segmental gradient pressure pneumatic appliance, 
neuromuscular stimulator, and electrical stimulator supplies. You say that because the treatment is properly 
indicated and is not experimental, unproven, or investigational, the Plan is required to pay for these services 
because the treatment is effective postoperatively for decreased deep vein thrombosis. The Plan denied your 
request. The Plan says the denial of these items and services were appropriate. 
 
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 DME setup fees, neuromuscular 
stimulator, and electrical stimulator supplies. Our reviewer says that you did not meet the criteria for coverage. 
Our physician reviewer found the provided records document the NMES was requested to prevent post-
operative disuse atrophy; records document you had 5/5 lower extremity strength, "without obvious atrophy" as 
of September 30, 2021. The records do not support that the NMES meets Medicare criteria for medically 
reasonable and necessary in this case. Our reviewer also found that the segmental gradient pressure pneumatic 
appliance is not covered by Medicare for the prevention of deep vein thrombosis. The NMES does not meet 
criteria for coverage. Our physician reviewer also found that as the DME does not meet criteria for necessity, 
the set-up component likewise does not meet criteria for necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME setup fees, segmental gradient pressure pneumatic appliance, 
neuromuscular stimulator, and electrical stimulator supplies have not been met. Specifically, the segmental 
gradient pressure pneumatic appliance is not covered because the base DME item is not covered. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (DME) setup fees (A9901), 
segmental gradient pressure pneumatic appliance (E0673), neuromuscular stimulator (E0745), and electrical 
stimulator supplies (A4595) provided on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, because the records do not knee instability on 
examination. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the enrollee has not had recent injury or surgery. The documentation doesnt support that the joint is 
unstable or that there is joint laxity.  The requested knee orthosis is not medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1852).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
August 18, 2022, to September 9, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity for this enrollee, and evidence based medical literature that 
substantiates the efficacy of the treatment rendered. The Plan denied your request. The Plan says the denial of 
the intermittent limb compression device was appropriate.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided from August 18, 2022, to September 9, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission provided from December 8, 2022, to December 
12, 2022. 
 
You asked the Plan to pay for the inpatient admission provided. You say that your physicians and staff 
provided medically necessary services to the enrollee in good faith. You also say that you would like the denial 
to be reconsidered and the claim processed for payment. The Plan denied your request. The Plan says that after 
receiving proper treatment in the emergency room, the enrollee's care could have been safely rendered at a 
lower level of care. 
 
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 pay for the inpatient admission provided. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case.  Our 
physician reviewer found the record shows that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 inpatient admission provided have been met. Therefore, we decided that the 
Plan has to pay for the inpatient admission provided from December 8, 2022, to December 12, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 2 standard, captains chair, 
patient weight capacity up to and including 300 pounds (K0823), u-1 sealed lead acid battery, each (e.g., gel 
cell, absorbed glassmat) (E2365) and adjustable height, detachable armrest, complete assembly (E0973). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says  there is no evidence of upper extremity weakness or postural instability 
necessitating a power wheelchair over a power scooter. The Plan states the mobility evaluation for the enrollee 
from April 3, 2023, which states the enrollee can ambulate one to two feet unassisted and 10 to 20 feet with a 
walker. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the documentation available for review does not support that the enrollee requires a power mobility 
device to accomplish mobility related self-care tasks in the home. There is no indication they are unable to use 
an alternative assistive device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair, group 2 standard, captains chair, patient weight capacity up to and 
including 300 pounds (K0823), u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (E2365) 
and adjustable height, detachable armrest, complete assembly (E0973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99238 rendered from May 23, 
2022 and June 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support 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 CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99238: 
 
Hospital discharge day management; 30 minutes or less 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesn't support the CPT code 99233. The documentation available for review does not support the enrollee 
developed a significant complication or that medical decision making of high complexity was needed. In this 
case, the documentation doesnt support the CPT code 99233. The documentation available for review does not 
support that the enrollee developed a significant complication or that medical decision making of high 
complexity was needed. 
 
Additionally, the time spent providing CPT 99238 was not documented in the records. This information is 
needed to bill this code. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99233 and 99238 rendered from May 23, 2022 and June 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that this is 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 that in this 
case, the documentation doesnt support that you require additional skilled rehab services to provide treatment 
that is medically necessary. You do not require additional skilled rehab services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. The requested home health services are not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for osteopathic manipulation treatment billed with code 98927 provided to the enrollee on July 18, 2022.
You asked the Plan to pay for these services . You say that this claim should 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 additional information. The Plan noted that the provider submitted medical records; however, the recorded date of service, which is August 22, 2022, does not match the claim date of service which is July 18, 2022.
Based on Medicare coding and payment standards, osteopathic manipulative treatment of 5-6 body regions, code 98927 is not the correct code to report when at least 5 conditions indicating somatic dysfunction of the head, cervical, thoracic, lumbar, sacral, pelvic, lower extremity, upper extremity, rib cage and abdomen and other body regions are not indicated on the claim. Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the records provided do not support the services billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for osteopathic manipulation treatment billed with code 98927 provided to the enrollee on July 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living 
and personal care. 
 
You asked the Plan to pre-approve the aide services. You say that you understand that the benefit is not 
covered. You also say that for this reason it was requested with a doctor's order for medical necessity and 
health. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at this physician's review, the file, and Medicare rules. There is no indication that you are receiving 
any home health skilled care. Based on this information, we decided that Medicare rules for coverage of the 
aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home visit 
for assistance with activities of daily living and personal care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional non-emergency transportation trip 
(A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation trip. You say that you are 
appealing the denial. The Plan denied your request. The Plan says your 24 trips have been used. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve an 
additional non-emergency transportation trip. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve an additional non-emergency transportation trip (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 17000 provided on June 23, 2022.
You asked the Plan to pay for this service . 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 information to show code 17000 has a global surgery indicator of 10. Medicare does not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. The claim history shows code 17000 was previously billed and paid to the same provider on June 14, 2022, under check number. The claim under appeal also billed code 17000 on date of service June 23, 2022, which is within the 10 day postoperative period. This service is included within the global day period and was denied appropriately.
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 appealed claim was submitted in error due to its global surgery indicator. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 17000 provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a OneTouch Ultra Test Strip. 
 
You asked the Plan to pre-approve a OneTouch Ultra Test Strip. You say that you would like approval for 
these test strips. 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 a OneTouch Ultra Test Strip. Therefore, we decided that the Plan does not have to pre-approve a OneTouch 
Ultra Test Strip.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (80307 and 83789) provided on September 16, 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 partially overturned the Plans denial and instructed payment of code 80307. Maximus denied code 83789. The Plan requested a reopen and demonstrated that there is a bundling edit for previously billed and paid procedure code 80305 and code 80307. The Plan provided that claim for review.
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 bundling edits for the codes billed and their inability to be separately paid.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (80307 and 83789) provided on September 16, 2022.