Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on September 16, 2022.
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus upheld the Plans denial. After the original decision was made it was determined the denial reason was not appropriate and the case was reopened.
Our Medical Director looked at the case file. At issue is coverage for physical therapy (PT) services provided on September 16, 2022 to an enrollee with temporomandibular joint (TMJ) disorder. The enrollee was a then 71-year-old woman with listed diagnoses of Muscle weakness (generalized), Right temporomandibular joint disorder, unspecified, and Radiculopathy, occipito-atlanto-axial region. The enrollee was referred to PT by a dentist. The initial PT evaluation took place on April 13, 2022, at which time the enrollee reported right TMJ pain that had gradually worsened over the previous few months. The treatment plan included soft tissue mobilization and stretching, dry needling, a progressive program of therapeutic exercise, a progressive program of neuromuscular re-education, and therapeutic modalities. One of the PT goals was, "The patient will be independent in a home exercise program in order to maintain gains made in therapy and prevent future problems." The plan was for a frequency and duration of "Initially 1 - 2 times weekly, decreasing in frequency as indicated by patient progression, for 15 sessions." The case file also contains a daily note which states the plan was to continue the current plan of care and progress program as appropriate. The source of the enrollee's TMJ symptoms is not clear from the PT documentation. Consequently, it cannot be determined that the symptoms are primarily medical in nature. Patients with TMJ disorder, particularly those with a prominent musculoskeletal component, or cervical or shoulder symptoms, are often referred for PT evaluation and treatment. However, there is a lack of high-quality data demonstrating the overall efficacy of physical therapy in the treatment of the disorder. In this case, the enrollee had previously been treated with outpatient therapies beginning in April of 2022. It is reasonably expected that she should have been independent with a home exercise program by September of 2022. There was no documentation of any recent injury or a decline in function. The additional therapy services were not of appropriate duration and frequency for treatment of the enrollee's condition, and therefore were 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee on September 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), arm pads (K0108 x2), mounting bracket assembly chest bar (K0108), and 
curved polyurethane seat liner (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, arm pads, 
mounting bracket assembly chest bar, and curved polyurethane seat liner. You say that the enrollee's quality of 
life will be greatly improved with the requested group 3 power wheelchair. The Plan denied your request. The 
Plan says arm pads are properly coded as K0019, is a replacement code, and cannot be covered on initial issue. 
The Plan says an accessory bar does not serve a medical purpose and cannot be covered. The Plan says K0108 
cannot be used for components of the wheelchair seat cushion. The Plan also says that although there are three 
requested power options (tilt, recline and elevating leg rests), there is not a medical need to control these power 
options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose. Medicare rules also say that if an option or accessory that is included in another code is billed 
separately, the claim line will be denied as not separately payable. 
 
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 electronic connection, harness, 
expandable controller, arm pads, mounting bracket assembly chest bar, and curved polyurethane seat liner. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has multiple sclerosis (MS) but is able to feed and groom 
themself independently. The enrollee has adequate upper body strength to manage standard power drives. Our 
reviewer found that the arm rests and seat pad requests cannot be unbundled from the wheelchair base or 
seating. Our physician reviewer also found that there is not medical justification for the chest bar.  
 
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 electronic connection, harness, expandable controller, arm pads, mounting 
bracket assembly chest bar, and curved polyurethane seat liner have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), arm pads (K0108 x2), mounting bracket assembly chest bar (K0108), and curved 
polyurethane seat liner (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to pay for physical therapy services provided to the enrollee on July 21, 2022.
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus upheld the Plans denial. After the original decision was made it was determined the denial reason was not appropriate and the case was reopened.
Our Medical Director looked at the case file. At issue is coverage for physical therapy (PT) services provided on July 21, 2022, to an enrollee with temporomandibular joint (TMJ) disorder. The enrollee was a then 71-year-old woman with listed diagnoses of Muscle weakness (generalized), Right temporomandibular joint disorder, unspecified, and Radiculopathy, occipito-atlanto-axial region. The enrollee was referred to PT by a dentist. The initial PT evaluation took place on April 13, 2022, at which time the enrollee reported right TMJ pain that had gradually worsened over the previous few months. The treatment plan included soft tissue mobilization and stretching, dry needling, a progressive program of therapeutic exercise, a progressive program of neuromuscular re-education, and therapeutic modalities. One of the PT goals was, "The patient will be independent in a home exercise program in order to maintain gains made in therapy and prevent future problems." The plan was for a frequency and duration of "Initially 1 - 2 times weekly, decreasing in frequency as indicated by patient progression, for 15 sessions." The case file also contains a daily note dated July 21, 2022, which states the plan was to continue the current plan of care and progress program as appropriate. The source of the enrollee's TMJ symptoms is not clear from the PT documentation. Consequently, it cannot be determined that the symptoms are primarily medical in nature. Patients with TMJ disorder, particularly those with a prominent musculoskeletal component, or cervical or shoulder symptoms, are often referred for PT evaluation and treatment. However, there is a lack of high-quality data demonstrating the overall efficacy of physical therapy in the treatment of the disorder. In this case, the enrollee had previously been treated with outpatient therapies beginning in April of 2022. It is reasonably expected that she should have been independent with a home exercise program by July of 2022. There was no documentation of any recent injury or a decline in function. The additional therapy services were not of appropriate duration and frequency for treatment of the enrollee's condition, and therefore were 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee on July 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on April 22, 2022.
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus upheld the Plans denial. After the original decision was made it was determined the denial reason was not appropriate and the case was reopened.
Our Medical Director looked at the case file. The enrollee was a then 71-year-old woman with listed diagnoses of Muscle weakness (generalized), Right temporomandibular joint disorder, unspecified, and Radiculopathy, occipito-atlanto-axial region. The enrollee was referred to PT by a dentist. The initial PT evaluation took place on April 13, 2022, at which time the enrollee reported right TMJ pain that had gradually worsened over the previous few months. The treatment plan included soft tissue mobilization and stretching, dry needling, a progressive program of therapeutic exercise, a progressive program of neuromuscular re-education, and therapeutic modalities. One of the PT goals was, "The patient will be independent in a home exercise program in order to maintain gains made in therapy and prevent future problems." The plan was for a frequency and duration of "Initially 1 - 2 times weekly, decreasing in frequency as indicated by patient progression, for 15 sessions." The case file also contains a Daily PT Note dated April 22, 2022. At that time, manual therapy and therapeutic exercise were performed. The plan was, "Continue the current plan of care and progress program as appropriate." The source of the enrollee's TMJ symptoms is not clear from the PT documentation. Consequently, it cannot be determined that the symptoms are primarily medical in nature. Patients with TMJ disorder, particularly those with a prominent musculoskeletal component, or cervical or shoulder symptoms, are often referred for PT evaluation and treatment. However, there is a lack of high-quality data demonstrating the overall efficacy of physical therapy in the treatment of the disorder. The documentation does not support that the PT for the treatment of TMJ disorder 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2023, billed with 
codes 87481, 87482, 87500, 87640, 87652, 87798, 87799, 87900. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was ordered based upon the 
treating physicians clinical training and medical necessity. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 8, 2023, billed with codes 87481, 87482, 87500, 87640, 87652, 87798, 87799, 87900.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on August 18, 2022.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. After the decision was made, an error was found, and the case was reopened.
Our Medical Director looked at the case file. At issue is coverage for physical therapy (PT) services provided on August 18, 2022, to an enrollee with temporomandibular joint (TMJ) disorder. The enrollee was a then 71-year-old woman with listed diagnoses of Muscle weakness (generalized), Right temporomandibular joint disorder, unspecified, and Radiculopathy, occipito-atlanto-axial region. The enrollee was referred to PT by a dentist. The initial PT evaluation took place on April 13, 2022, at which time the enrollee reported right TMJ pain that had gradually worsened over the previous few months. The treatment plan included soft tissue mobilization and stretching, dry needling, a progressive program of therapeutic exercise, a progressive program of neuromuscular re-education, and therapeutic modalities. One of the PT goals was, "The patient will be independent in a home exercise program in order to maintain gains made in therapy and prevent future problems." The plan was for a frequency and duration of "Initially 1 - 2 times weekly, decreasing in frequency as indicated by patient progression, for 15 sessions." The case file also contains a note dated August 18, 2022. At that time, manual therapy and therapeutic exercise were performed. The plan was, "Continue the current plan of care and progress program as appropriate." The source of the enrollee's TMJ symptoms is not clear from the PT documentation. Consequently, it cannot be determined that the symptoms are primarily medical in nature. Patients with TMJ disorder, particularly those with a prominent musculoskeletal component, or cervical or shoulder symptoms, are often referred for PT evaluation and treatment. However, there is a lack of high-quality data demonstrating the overall efficacy of physical therapy in the treatment of the disorder. In this case, the enrollee had previously been treated with outpatient therapies beginning in April of 2022. It is reasonably expected that she should have been independent with a home exercise program by August 2022. There was no documentation of any recent injury or a decline in function. The additional therapy services were not of appropriate duration and frequency for treatment of the enrollee's condition, and therefore were 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 this service have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99205) rendered on February 
17, 2023. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT) code 99205 remains not supported, as the documents do not 
support this level of care. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter."  
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 visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the documentation states that 60 
minutes were spent on the appointment, with a comprehensive exam reflected in the records. However, the 
records do not support a comprehensive history or a high level of decision making. 
 
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 visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99205) rendered on February 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
March 08, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. 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 a $350 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $350 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an outpatient diagnostic tests provided on March 08, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
March 30, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. 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 a $20 
copayment for outpatient diagnostic tests/Medicare-covered outpatient diagnostic tests.. 
 
You have been asked to pay a $20 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered outpatient diagnostic tests. benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an outpatient diagnostic tests provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on March 08, 2023. 
 
You asked the Plan to pay for injections. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
March 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on August 15, 2022. 
 
You asked the Plan to pay for injections. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
August 15, 2022.