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

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27279). 
 
You asked the Plan to pre-approve SI joint fusion. 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 SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no imaging of the SI joint which explains your pain. You do not have an indication 
such as trauma, tumor or infection. Therefore, the request is deemed 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 SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27279).
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 are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the request is not medically necessary.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 pay for the co-surgeon services described by code 35656-62 
performed on July 21, 2023. 
 
You asked the Plan to pay for 35656-62. You say that 35656-62 should be paid as billed because records 
support these co-surgeon charges and modifier -62 was appended. The Plan denied your request. The Plan says 
35656-62 is denied because documentation does not support that each surgeon was working as a primary 
surgeon performing distinct parts of the procedure. 
 The Plan must follow Medicare rules. Medicare rules say that if two surgeons (each of a different specialty) are 
required to perform a specific procedure, each surgeon bills for the procedure with modifier -62. 
 
We looked at the file and Medicare rules. We confirmed that modifier -62 was appended to 35656. Medicare 
rules state that modifier -62 is for use when two surgeons of different specialties are required to perform a 
specific procedure. In this case, we confirmed that both surgeons billing code 35656-62 have the same 
specialty of vascular surgery and the same primary taxonomy code. This means that the use of modifier -62 is 
not supported. Based on this information, we decided that Medicare rules for coverage of 35656-62 have not 
been met. Therefore, we decided that the Plan does not have to pay for the co-surgeon services described by 
code 35656-62 performed on July 21, 2023.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says IRF services are not medically necessary.  
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed with procedure code 87801 
provided on June 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services billed with procedure code 87801. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit when provided by an OON 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 
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 laboratory services billed with procedure code 
87801 provided on June 23, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on February 01, 2023, to April 03, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the copayment. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs 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 coinsurance 
for Medicare Part B prescription drugs provided on February 01, 2023, to April 03, 2023.
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 fell, had hip surgery, and need to be functioning 
as you were prior to your fall. You also say that if you return home, you believe you will end back up in the 
hospital from complication. The Plan denied your request. The Plan says based on the available information, 
admission to an IRF is not reasonable and necessary.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer found that while the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. Our physician reviewer also found that 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.  
 
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 waive the coinsurance for the office visit provided on August 9, 
2023. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that you have never had to pay for an 
office visit in the past with this provider. 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 40% 
coinsurance for an out-of-network Medicare-covered primary care physician office visit.  
 
You have been asked to pay $44.27, which is 40% coinsurance of the allowed amount for the office visit. 
($110.67 allowed amount x 40% coinsurance = $44.27). This item/service falls within the physician/practitioner services, including doctors office visits 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 coinsurance for the office visit provided on August 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 15275, 15276, and A2001 rendered on May 
31, 2023. 
 
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: 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A). 
 
The CPT code manual definition of the denied codes: 
 
CPT 15275: 
 
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, 
and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 
 
CPT 15276: 
 
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, 
and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, 
or part thereof (List separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) A2001: 
 
Innovamatrix ac, per square centimeter 
 
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 the medical records indicate the 
skin substitute procedure was performed on the leg, which is not consistent with the description of CPT code 
15275, therefore this procedure cannot be verified. CPT 15276 is an add-on code, which requires a valid, 
approved primary code in order to be eligible for reimbursement consideration. In this case, the primary code, 
15275 could not be verified, therefore 15276-76 is not separately reimbursable. In addition, the medical records 
indicate the skin substitute procedure was performed on the leg, which is not consistent with the description of 
CPT code 15276 therefore this procedure cannot be verified. Finally, the medical records provided indicate 
human allograft tissue was used, which does not align with the description of HCPCS code A2001; therefore, 
this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 15275, 15276, and A2001 rendered on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for these dental services.

You asked the Plan to provide coverage for these dental services. The Plan denied your request. The Plan says
your benefit for the requested item or service has already been exhausted. Maximus partially overturned the
Plans denial. The Plan requested a reopen and provided additional information. The Plan sent documentation to
show that you reached the maximum benefit for crowns in 2023. The Plan notes in the initial evaluation their
Dental Department approved a portion of these services which causes you to reach the maximum benefit of 4
crowns being covered per year, per the Plan contract.

The Plan is correct in this case. 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 more than Medicare coverage, certain limitations apply, and you had
reached the benefit maximum for this service per the Plan contract. Therefore, we decided that the Plan does
not have to provide coverage for all of the requested dental services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alimta (J9305). 
 You asked the Plan to pre-approve Alimta. You say that you are requesting an urgent authorization because the 
patient is there now. The Plan denied your request. The Plan says the information does not show that the patient 
meets the coverage criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Alimta. Our reviewer says that the 
patient does not meet the coverage criteria for Alimta. Our physician reviewer found the provided records do 
not indicate that the patient has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the patient has a contraindication to, or would have an adverse effect from the Plan's preferred step 
one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested drug cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alimta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Alimta (J9305).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory panel testing provided on June 20, 2023. 
 
You asked the Plan to pay for lab panel. You say that this was medically necessary and was a distinct 
procedure requiring separate reimbursement. The Plan denied your request. The Plan says a single procedure 
code that supports the panel should have been reported. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular syndromic panels for infectious 
disease pathogen identification must be billed with a single proprietary panel code or with code 87999.  
 
We looked at the file and Medicare rules. This lab panel was not billed with the appropriate single procedure 
code. Based on this information, we decided that Medicare rules for coverage of lab panel have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory panel testing provided on June 20, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on August 26, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that procedure code 
99284 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 an emergency department visit (procedure 99284). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the records support an appropriate history and examination but does not support a moderate level of decision-
making to justify the code, 99284 as the patient was stable and did not require complex treatment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99284) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99284) 
provided on August 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on February 05, 2023, to May 05, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the copayment. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 coinsurance 
for durable medical equipment (DME) provided on February 05, 2023, to May 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildups (D2950) provided on March 31, 2023.

You asked the Plan to pay for the core buildups. You say that the dental services were necessary because there
would be inevitably decay due to wear and tear on the teeth. The Plan denied your request. The Plan says that
core buildups are not covered. Maximus partially overturned the Plan's denial based on medical necessity. The
Plan requested a reopening and states that these services were not denied for medical necessity but for not
being a covered benefit. The Plan is correct in this case. The Plan's Dental Benefits Addendum does not
include core buildups as a covered service. 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 core buildups (D2950) provided on March 31, 2023.