Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A4239). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found that the record does not indicate the enrollee is on insulin or have a history of problematic hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM) (A4239).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be currently unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
patient does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as the patient is not stable for transfer and as it would not be clinically 
advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for periodontal scaling and root planing-four or
more teeth per quadrant (D4341 x 4).

You asked the Plan to provide coverage for these services. The Plan denied your request. The Plan says the
required coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and
noted that although you have abnormal pocket depths, the criteria requires that you must also have either
radiographic evidence of root surface calculus or radiographic evidence of loss of bone support. As this is not
seen in dental x-rays provided, the required criteria were not met.

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.
The Plan covers this type of dental service when specific criteria are met. Based on the dental records provided,
you did not meet those criteria. Therefore, we decided that the Plan does not have to provide coverage for
periodontal scaling and root planing-four or more teeth per quadrant (D4341 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a complete lower denture (D5120) and
complete upper denture (D5110).

You asked the Plan to provide coverage for these services. You say that your existing dentures are too wide and
bulky and cause pain. The Plan denied your request. The Plan says you have exhausted the benefit limit.
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. The Plan covers one upper
denture every 60 months and one lower denture every 60 months.

We looked at the file and the Plan's rules. The file shows that you previously received a complete upper
denture and a complete lower denture on October 18, 2021.

You are not eligible for new dentures until 60 months have passed from this date. Based on this information,
we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to provide coverage for a complete lower denture (D5120) and complete upper denture
(D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for circulating tumor cell (CTC) assay testing provided on 
November 11, 2021. 
 
You asked the Plan to pay for CTC testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says this testing should have been billed with 1 unit of code 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that CTC assay testing must be billed with 1 unit of 
procedure code 81479.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of CTC testing have not been met. Therefore, we 
decided that the Plan does not have to pay for circulating tumor cell (CTC) assay testing provided on 
November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit and the lesion destruction procedure 
provided on May 10, 2023, by an OON provider.  
 
You asked the Plan to pay for the specialist office visit and the lesion destruction procedure. You say that you 
are appealing the denial with supporting medical records. The Plan denied your request. The Plan says these 
services were not authorized. 
 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 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 specialist office visit and the lesion destruction 
procedure provided on May 10, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5102 billed for date of service November 1, 
2022, to December 28, 2022. 
 
You asked the Plan to pay for procedure code S5102. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S5102 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5102 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5102 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5102 billed for date of service November 1, 2022, to December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for dates of service April 4, 
2023, and April 5, 2023. 
 You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code 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 code. 
 
We looked at the file and the rules. The medical records provided do not document the dates of service at issue. 
The date the records were authored is not sufficient evidence to identify when the services were provided. 
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 code 99232 billed for dates of 
service April 4, 2023, and April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water-circulating heat pad with pump (code E0217) 
billed for dates of service September 28, 2022, to October 19, 2022. 
 
You asked the Plan to pay for code E0217. You say that this item was medically necessary. The Plan denied 
your request. The Plan says this item is not covered. The Plan must follow Medicare rules. The rules say that 
water circulating heat pads with pump (E0217) are excluded from coverage. Therefore, we decided that the 
Plan does not have to pay for code E0217 billed for dates of service September 28, 2022, to October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided February 6, 2023, billed with 
codes 87481, 87653, 87798 and 87803. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Also, the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture 
and sensitivity.  Based on this information, we decided that Medicare rules for coverage of the laboratory 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel 
provided February 6, 2023, billed with codes 87481, 87653, 87798 and 87803.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 18, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that code 76641 was billed correctly and should 
be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1 unit. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service July 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 16, 2023, to 
April 26, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 16, 2023, to April 
26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service June 24, 
2023. 
 You asked the Plan to pay for procedure code 71045-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 71045-26 is bundled into 
payment for code 36556-RT. 
 
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 
71045-26 is a column II code to column I code 36556-RT. 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 71045-26 billed for date of service 
June 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 18, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.

You asked the Plan to pre-approve acupuncture. The Plan denied your request. The Plan says the contract is
clear that acupuncture benefits must be paid for by the enrollee and then submitted for payment after the fact
under the wellness allowance benefit. Maximus overturned the Plans denial. The Plan requested a reopen and
noted that Maximus did not apply the contract rules correctly.

The Plan is correct in this case. The rules say that acupuncture services are not covered by Medicare. The Plan
will reimburse acupuncture services under the wellness allowance benefit. This benefit allows $150 per year
for services not covered by the Plan or by Medicare. However, these types of services cannot be pre-approved
by the Plan as the provider cannot be reimbursed through the Medicare payment structure.

Enrollees must pay for the services first and ask for reimbursement through the program. If there are not
enough funds available in the program or the $150 benefit is exhausted, the Plan is not required to pay for these
services. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria.  
 
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 can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy. There is documentation that there is a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF, but the services required 
can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart permanent cardiac contractility 
modulation (CCM) system (0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart system. 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 Optimizer Smart system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, CCM remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. 
 
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 Optimizer Smart system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart permanent cardiac contractility modulation (CCM) 
system (0408T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on December 6, 2022, billed 
with codes 87541 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on December 6, 2022, billed with codes 87541 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 31, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the OIVIT services should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says the OIVIT 
services are denied because they are not supported and there is another more appropriate code to use for these 
services. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Qutenza kit. 
 
You asked the Plan to pre-approve a Qutenza kit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says your plan does not include Part D prescription drug coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve a Qutenza kit.  
 
  Benefits for a Qutenza kit may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 24, 2023, to May 
23, 2023. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 24, 2023. The NOA was not received by the Plan until June 6, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
April 24, 2023, to May 23, 2023.