Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99291. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 93042.  
 
You asked the Plan to pay for imaging services provided on November 20, 2022. You say that the claim was 
billed correctly and should be paid. The Plan says that payment for this code is bundled into payment for code 
99291. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99291.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99291.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
93042. 
 
The Plan follows Medicare rules. Medicare rules say that for edits with a modifier indicator of 0, the Column 2 
code cannot be paid regardless of whether a modifier is used. In this case, we have confirmed that code 93042 
is a column II code to column I code 99291. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 93042. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that these services were reported correctly. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785, 95861, and 95870 for date of service 
June 15, 2022. 
 
You asked the Plan to pay for procedure codes 51785, 95861, and 95870. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are 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. 
 
We find that CPT codes 51785, 95861, and 95870 are not supported in the medical record. Specifically, the 
technical report did not include documentation of a needle electromyography studies (EMG) of anal or urethral 
sphincter, any technique; therefore, code 51785 cannot be verified. 
 
The technical report did not include documentation of a Needle electromyography; 2 extremities with or 
without related paraspinal areas; therefore, code 95861 cannot be verified. 
 
The technical report did not include documentation of a Needle electromyography; limited study of muscles in 
1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve 
supplied muscles, or sphincters; therefore, code 95870 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 51785, 95861, and 
95870 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 51785, 
95861, and 95870 for date of service June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, and 
harness upgrade. 
 
You asked the Plan to pre-approve upgraded electronics. You say that the enrollee's current wheelchair is 
falling apart. You say that the enrollee is unable to walk and has chronic obstructive pulmonary disease 
(COPD). You also say that the enrollee does not have enough motor strength of upper body to propel a manual 
wheelchair. The Plan denied your request. The Plan says there is not a medical need to control the power 
options through a joystick. 
 
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 upgraded electronics. Our reviewer says 
that the requested upgraded electronics are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not support that the enrollee requires a joystick to 
control the power options that were approved for the power wheelchair. Therefore, the reviewer found that the 
requested upgraded electronics are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection, expandable controller, and harness upgrade.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code G0452. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0452 is bundled into payment for code 81445. 
 
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 G0452 
is a column II code to column I code 81445. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 G0452 billed for date of service October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you need these items. The Plan 
denied your request. The Plan says a total electric hospital bed is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
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 July 29, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the enrollee's treating physician order the test. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the gene panel was billed using multiple codes, including CPT code 81347. If a single procedure 
is performed, only one code with one unit of service may be reported for the procedure. Based on this 
information, we decided that Medicare rules for coverage of the testing 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 July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and the 
betamethasone acetate injection provided on December 5, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visit and the injection. You say that the 
claim was processed at an out-of-network benefit level. 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 $30 
copayment for each in-network Medicare-covered specialist visit. Your contract with the Plan also clearly says 
that you must pay a 20% coinsurance for in-network Medicare-covered Part B drugs. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. You have also been asked to 
pay $1.36, which is 20% coinsurance of the allowed amount for the injection ($6.82 allowed amount x 20% = 
$1.36). 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 copayments for the specialist office visit and the betamethasone acetate injection 
provided on December 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from September 22, 2022, to October 21, 2022.

You asked the Plan to pay for the home health services as billed. You say that the services at issue have been billed correctly. 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 September 22, 2022, to October 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director reviewed the reopen and the case file. At issue is coverage for IRF services.
The Maximus Physician Reviewer determined that the requested IRF care was medically reasonable and necessary for the enrollee in this case. The Plan requested a reopen based on the required criteria not being met. The medical records show the enrollee was a then 60-year-old woman with a medical history that included diabetes, hypertension, end stage renal disease (ESRD) on dialysis, alcoholic cirrhosis with ascites, and anemia. The enrollee was hospitalized on September 15, 2022, with superior and inferior fractures of the pubic ramus suffered in a fall. On October 5, 2022, the Hospitalist Progress Note documented that physical therapy severe pain with mobility and required max assistance with moving out of bed. The enrollee was to resume her regular hemodialysis schedule. On October 6, 2022, the enrollee minimal assistance for bed mobility. The enrollee ambulated 80 feet using a rolling walker with care give assistance. The Plan is correct in this case. The documentation does not support that the complexity of this enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63048, 63053, and 62350 billed for August 
25, 2022. 
 
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 procedure codes 63048, 63053, and 62350 are 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 63048 is laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or 
lumbar (List separately in addition to code for primary procedure). The definition of code 63053 is 
laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, 
lumbar; each additional vertebral segment (List separately in addition to code for primary procedure). The 
definition of code 62350 is implantation, revision or repositioning of tunneled intrathecal or epidural catheter, 
for long-term medication administration via an external pump or implantable reservoir/infusion pump; without 
laminectomy. 
 
We find that CPT codes procedure codes 63048, 63053, and 62350 are not supported in the medical record. 
Specifically, there is no documentation of a single vertebral segment for a laminectomy, facetotomy, and 
foraminotomy to support code 63048. There is no documentation of a unilateral or bilateral laminectomy, 
facetectomy, or foraminotomy of the lumbar spine to support code 63053. There is no documentation of an 
implantation of a revision or repositioning of tunneled intrathecal or epidural catheter to support code 62350. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 63048, 63053, and 62350 billed 
for August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure) (64628).
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap when adequate relief is not achieved from traditional conservative treatment. The Plan denied your request. The Plan says that the requested procedure is not medically necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for the Intracept procedure. Our Medical Director states that one double-blind randomized study has shown that improvement with the Intracept procedure was not clinically significant when compared with a sham procedure. Additional studies suggest that the Intracept procedure may be more effective for low back pain than conservative treatment. Limitations of the published medical literature include a limited number of studies, industry funding of the studies, and a high risk of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to compare it to other interventions.
Current medical literature indicates that the Intracept procedure is investigational at this time. In addition, imaging studies show moderate spinal stenosis and neural foraminal narrowing that could explain the source of the enrollee's pain. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of the Intracept 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure) (64628).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal SNF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The enrollee was a then 75-year-old woman with a medical history that included breast cancer and alcohol dependence. The enrollee was diagnosed with a C5-6 cervical fracture with anterolisthesis and associated central cord syndrome. Surgery was performed. The enrollee had wounds on her coccyx, right heel, tracheostomy, post-operative site, and left wrist external fixator. The Plan is correct in this case. The documentation does not support that the transfer from the IRF to a SNF was medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services.
The Maximus Physician Reviewer. IRF criteria were met. The Plan requested a reopen and argues the enrollee had not completed his full hospital course. The Plan stated the treating physician noted on October 24, 2022, that the enrollee continued to have a supratherapeutic INR and suspected that the hematoma was pressing on the sciatic nerve. His physician stated they would "await INR levels to come down" and he was not yet ready for placement. The physical therapist noted the enrollee was limited by significant right lower extremity pain, described as "sciatic like." The physical therapist also documented developing weakness in the right leg, as well as a positive straight leg raise, "indicating decreased sciatic nerve glide." The Plan notes IRF care is not covered by Medicare unless the enrollee has completed their hospital course and can be reasonably expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program. The Plan is correct in this case. The documentation does not sufficiently support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. The Plan denied your request. The Plan 
says you have exhausted your transportation benefit. 
 
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. 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 additional trips for routine transportation beyond the Plan's 
24-trip limit.