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

 
We decided that the Plan does not have to pay for procedure code 95957 billed on date of service January 9, 
2023. 
 
You asked the Plan to pay for 95957. You say that 95957 should be paid as billed because it was billed 
correctly. The Plan denied your request. The Plan says 95957 is denied because it is not supported in the 
documentation. 
 
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 95957 is digital analysis of electroencephalogram (EEG) (for example, for epileptic spike analysis). 
 
We find that CPT code 95957 is not supported in the medical record. Specifically, according to the CPT 
Assistant, December 2018, Volume 28, Issue 12, 95957 is intended to be reported with EEG codes 95812, 
95813, 95816, 95819, 95822 and 95951. We confirmed that no EEG testing code was billed for this date of 
service. Because of this, the digital analysis of an EEG is not supported. Based on this information, we decided 
that Medicare rules for coverage of 95957 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95957 billed on date of service January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a flex-walk system (L5981), axial rotation
unit (L5984), alignable system (L5910) and vertical shock reducing pylon (L5988).
You asked the Plan to provide coverage for a flex-walk system (L5981), axial rotation unit (L5984), alignable,
e system (L5910) and vertical shock reducing pylon (L5988). You say that this equipment is 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 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 an alignable
system (L5910) and vertical shock reducing pylon (L5988). The Maximus Physician Reviewer determined that
the requested prosthetic components are medically necessary.
The Plan requested a reopen and stated the medical records do not show why enrollee's current L5910 alignable
system cannot be used for the approved replacement socket. The records do not show medical necessity for
L5988.
The records show the enrollee is a 62-year-old woman who previously underwent a right leg below-knee
amputation. The Plan is correct in this case. The available clinical documentation does not support that the
alignable system and vertical shock reducing pylon were 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 this request have not been met. Therefore, we decided that the Plan does not have
to provide coverage for a flex-walk system (L5981), axial rotation unit (L5984), alignable system (L5910) and
vertical shock reducing pylon (L5988).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 3, 2023, to June 4, 
2023, billed with evaluation and management (EM) codes 99223-AI and 99232-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 99223-AI and 99232-25 is initial hospital inpatient or 
observation care, per day, for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making. When using total time on 
the date of the encounter for code selection, 75 minutes must be met or exceeded, and subsequent hospital 
inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using 
total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that none of the documentation provided 
supports a high level of medical decision-making of the initial visit, nor do subsequent visit documentation 
support moderate decision-making. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 3, 2023, to June 4, 2023, billed with 
evaluation and management (EM) codes 99223-AI and 99232-25.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DecisionDx-Melanoma test (81529). 
 
You asked the Plan to pre-approve the genetic testing. You say that the test was ordered by the treating 
physician with the intent to use the DecisionDx-Melanoma test results to inform treatment decisions. The Plan 
denied your request. The Plan says the records do not support that the enrollee meets all of the Medicare 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not meet the first criteria indicated listed in the LCD. The enrollee 
has a T1a lesion without documentation showing concern for adequacy of microstaging.  
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the DecisionDx-Melanoma test (81529).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that  you would like to request reconsideration of the 
denied PET scan of the brain and that the services requested are medically necessary.  The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there was no documentation provided 
indicating that the enrollee is suspected of having either, let alone both AD and FTD. There was no indication 
that they met diagnostic criteria for either disorder. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown restoration for tooth #26.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the criteria for coverage are not met.
Medicare provides coverage for services shown to be reasonable and necessary. The Plan covers dental
services when the services are medically necessary and reasonable. We asked our physician reviewer to
carefully review the case file and apply the relevant rules to determine if the Plan was correct in denying the
request to pre-approve these services. Our physician reviewer found the records show that there is significant
coronal breakdown on tooth #26 due to caries and fracture, which appears to be accessible. There is good bone
support and long-term retention of the tooth would be more likely with a crown restoration. The criteria for
coverage are met and the requested crown is medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
criteria for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a
crown restoration for tooth #26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 6 office visits and treatment with an out-ofnetwork
(OON) general surgery provider.
You asked the Plan to provide coverage for the requested out of network provider. You say that surgery with
the requested out of network provider is likely to lead to a better medical outcome and ultimately could
be less costly. The Plan denied your request. Maximus overturned the Plans denial. The Plan requested a
reopen and submitted additional information. The Plan noted that both the network provider the Plan referred
you to and the out of network provider your requested are General Surgeons with a surgical-oncology specialty.
The facility you were referred to by the Plan is also a high-volume, 50-60 Whipple procedures per year as well
as being in the process of applying for a pancreatic cancer center of excellence designation status.
Based on this information, referral in network was a viable option for your treatment.
The Plan is correct in this case. 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 pre-approve care from out-of-network providers
only in cases involving emergencies, out of area urgent care and care that cannot be provided by network
providers. The requested is not a network provider with the Plan. The Plan demonstrated it has network
providers available who can provide the items/services at issue in this appeal. We found no exception that
would require the Plan to provide coverage for out of network services. Therefore, we decided that the Plan
does not have to provide coverage for 6 office visits and treatment with an out-of-network (OON) general
surgery provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total hip replacement. 
 
You asked the Plan to pre-approve a right total hip replacement. 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 a right total hip replacement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The height, weight, and body mass 
index are not documented. The provided objective examination findings did not corroborate significant deficits of the right hip. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. Therefore, the requested right total hip replacement is 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 a right total hip replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right total hip replacement.
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 16, 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 $150 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for an outpatient diagnostic tests. This item/service falls within 
the 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. However, since the allowed amount is less than the standard copayment, you only owe 
$69.06. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient diagnostic 
tests provided on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 14, 2023. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits and the x-rays provided on May 24, 2023, to 
May 31, 2023. 
 
You asked the Plan to pay for the office visits and the x-rays. You say that you are requesting reconsideration 
of the denied claims. 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 the office visits and the 
x-rays provided on May 24, 2023, to May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS)
supplies provided on October 18, 2022.
You asked the Plan to pay for this claim. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct billing criteria. The Plan noted that Claim history shows this provider, has
been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Local Coverage
Article A52520, during the rental of a TENS unit, supplies for the unit are included in the rental allowance;
there is no additional allowance for items such as electrodes, lead wires, and batteries. Since the provider is
renting the TENS Unit to the member the provider should not bill for supplies as stated in the LCD A52520.
It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator
supplies, 2 lead, per month) which exceeds the Medicare allowed amount.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid as billed due to errors with shipping supplies
for a rented item and billing them separately and shipping supplies whose quantities exceed the Medicare
allows amount to ship. Medicare rules for coverage of this claim have not been met. Therefore, we decided that
the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies provided on
October 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the arthrodesis procedure of the 
metacarpophalangeal joint provided by an in-network provider on June 19, 2023. 
 
You asked the Plan to waive the cost sharing for the arthrodesis procedure. You say that you were given 
incorrect information regarding your deductible. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to outpatient surgery services, and 
that you must pay a $200 copayment per day, after the deductible, for other in-network outpatient procedures 
and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery 
performed in an ambulatory surgical center. 
 
You have been asked to pay a $200 copayment for the arthrodesis procedure. You have also been asked to pay 
a $1000 deductible for the arthrodesis procedure. The item or service you asked the Plan to waive the cost 
sharing for falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1000 deductible which applies to outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that 
had not been met at the time the arthrodesis procedure was provided on June 19, 2023. Therefore, we decided 
that the Plan does not have to waive the cost sharing for the arthrodesis procedure of the metacarpophalangeal 
joint provided by an in-network provider on June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 15, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory service 
provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 19, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that all services were medically 
necessary. 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 subsequent nursing 
facility care provided on April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult-size disposable diapers (i.e., incontinence 
supplies).  
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs these items due to 
incontinence.  You said that the enrollee is wetting the bed and her clothes. The Plan denied your request. The 
Plan says diapers are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult-size disposable diapers 
(i.e., incontinence supplies).