Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional home health physical therapy (PT)
visits (G0151) for the enrollee.

You asked the Plan to pre-approve four (4) additional home health (PT) visits. You say that these services are
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for four (4) additional
home health (PT) visits. Our Medical Director states that the enrollee has a history of osteoarthritis of the right
knee who underwent right knee replacement surgery. The enrollee had 12 physical therapy visits approved. On
June 29, 2023, the enrollee was making good gains toward her goals. On July 5, 2023, the enrollee had much
improved home gait. She needed to rest after about 125-150 feet. The enrollee could walk 150 feet on level
surfaces with a walker and could walk 100 feet on uneven surfaces with a walker. The enrollee required little to
no help with moving in bed and standing up. The enrollee had caregivers available who can help with many
daily living tasks. The clinical documentation does not support that four additional home physical therapy visits
were required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of
function, or to establish/perform a maintenance program to maintain level of function and/or prevent
deterioration. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of
four (4) additional home health (PT) visits.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of four (4) additional home health (PT) visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve four (4) additional home health physical therapy (PT) visits
(G0151) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a fall and has a broken hip and 
femur. They had surgery and is unable to sit up or stand up and is needing a higher level of care. The Plan 
denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not 
meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an epidural steroid injection (ESI).

You asked the Plan to provide coverage for an epidural steroid injection (ESI). You say that at the time of the
appeal, this injection was medically necessary. The Plan denied your request. The Plan says the required
Medicare criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct criteria. The Plan noted that the medical records provided do not show
you have lumbar, cervical, or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to
central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing
foraminal or central spinal stenosis; or post-laminectomy syndrome, acute herpes zoster associated pain or
spinal stenosis at the T3-4 level. However, the Plan notes the magnetic resonance imaging (MRI) shows a
chronic compression fracture deformity at T3 with 20% height loss and no retropulsion of fracture fragments.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare requires specific documentation be present in the medical records to
show all the required coverage criteria are met at the time of the appeal. We looked at the file and Medicare
rules. Based on this information, we decided that there is insufficient information in the record to show the
required coverage criteria were met at the time of the appeal. Therefore, we decided that the Plan does not have
to provide coverage for an epidural steroid injection (ESI).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic metabolic panel (80048), complete blood count 
(CBC) (85025), assay of magnesium (83735), and morphine sulfate injection (J2270) provided on October 5, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the basic metabolic panel, CBC, assay of magnesium, and morphine sulfate 
injection. You say that you are respectfully requesting reconsideration of the denial, retrospective review, 
authorization, and payment for the urgent medically necessary services provided to the enrollee. The Plan 
denied your request. The Plan says the treating provider is not a network provider with the Plan. The Plan also 
says that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the basic metabolic panel (80048), complete blood 
count (CBC) (85025), assay of magnesium (83735), and morphine sulfate injection (J2270) provided on 
October 5, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057 x 2) and crown 
porcelain/ceramic (D2740 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve custom fabricated abutment (D6057 x 2) and crown porcelain/ceramic (D2740 x 3).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) and speech therapy services
(92507, 92526) provided to the enrollee from January 6, 2023, to January 18, 2023.

You asked the Plan to pay for any of these services. You say that this claim should be paid. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan
noted that a Procedure to Procedure (PTP) edit exists between codes 92507 and 97530 and codes 92526 and
97530. The claim shows that codes 97530 and 92507 were both billed on January 6, 2023, January 10, 2023,
and January 12, 2023. The claim shows that codes 97530 and 92526 were both billed on January 17, 2023.
Medicare developed the National Correct Coding Initiative (NCCI) program to prevent inappropriate payment
of services that should not be reported together. NCCI Procedure-to-Procedure (PTP) edits were placed into
either the "Column One/Column Two Correct Coding Edit Table" or the "Mutually Exclusive Edit Table. Each
edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together.
Each edit has a Column One and Column Two HCPCS/CPT code. If a provider or supplier reports the 2 codes
of an edit pair, the Column Two code is denied, and the Column One code is eligible for payment. As there
were no modifiers that would allow the edit to be overridden as a separate or unrelated service, the claim was
denied.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code. In this case, this claim could not be paid as billed due
to the NCCI PTP edit requirements that exist for the codes billed and the lack of a modifier to separate the
billing.

The Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for
therapeutic activities (97530) and speech therapy services (92507, 92526) provided to the enrollee from
January 6, 2023, to January 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay from June 13, 2023, through 
June 30, 2023. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you did not have more than 20 days 
of SNF, so you should have a $0 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 in-
network days 1-20: $0 copayment per day and for days 21-100: $188 copayment per day. 
  You have been asked to pay a total of $752 for the SNF stay. This item/service falls within the skilled nursing 
facility (SNF) care benefit category. The records show that you had a seven-day SNF stay from June 2, 2023, 
through June 9, 2023, and a 17-day SNF stay from June 13, 2023, through June 30, 2023. The total of your 
SNF stays is 24 (7 days + 17 days = 24 total days), therefore, you have 4 days at the $188 per day rate (4 days x 
$188 per day = $752). 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 the SNF stay from June 13, 
2023, through June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 30, 
2023. 
 
You asked the Plan to pay for the dental service. You say that this service was urgent. You also say that you 
ended up having a tooth extracted. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for this service was exhausted on date of service June 20, 2023. Therefore, we decided that 
the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit, an ultrasound, the injection 
services, and the application of an unna boot provided on June 12, 2023. 
 
You asked the Plan to waive the cost share for an office visit, an ultrasound, the injection services, and the 
application of an unna boot. You say that you were not told of the cost share. 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 $490 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
You have been asked to pay $93.54 towards your deductible for the office visit. You have also been asked to 
pay $30.68 towards your deductible for the injection services. You have also been asked to pay $65.94 towards 
your deductible for the application of an unna boot. The items or services you asked the Plan to waive the cost 
share for fall within the physician/practitioner services, including doctor's office visits benefit category. You 
have also been asked to pay $44.06 towards your deductible for the ultrasound. The item or service you asked 
the Plan to waive the cost share for falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $490 deductible which applies to physician/practitioner services, including doctor's office visits. This cost 
sharing is a contractual obligation that had not been met at the time an office visit, an ultrasound, the injection 
services, and the application of an unna boot was received on June 12, 2023. Therefore, we decided that the 
Plan does not have to waive the cost share for an office visit, an ultrasound, the injection services, and the 
application of an unna boot provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a porcelain/ceramic dental crown for tooth number
2 (D2740).

You asked the Plan to provide coverage for a porcelain/ceramic dental crown for tooth number 2 (D2740). You
say that at the time of the appeal, these dental services were necessary. The Plan denied your request. The Plan
says the required dental criteria were not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct contract criteria. The Plan noted that the contract
criteria for coverage of a crown on permanent molar teeth (such as tooth #2), requires pathologic
destruction to the tooth by caries or trauma, and should involve four or more surfaces and at least two or
more cusps. The submitted dental records did not indicate presence of pathologic destruction to the tooth by
caries or trauma that involves four or more surfaces and at least two or more cusps. Therefore, the records
provided do not support the services requested.

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 requires specific dental records to show the requested service meets the Plans contract criteria.
Based on the dental records provided, the Plan's rules for coverage of a porcelain/ceramic dental crown for
tooth number 2 (D2740) have not been met. Therefore, we decided that the Plan does not have to provide
coverage for a porcelain/ceramic dental crown for tooth number 2 (D2740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous radiofrequency ablation of the 
basivertebral nerve.  
 
You asked the Plan to pre-approve the intraosseous radiofrequency ablation of the basivertebral nerve. You say 
that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The 
Plan says the intraosseous ablation of the basivertebral nerve is not medically necessary. 
 
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 intraosseous radiofrequency 
ablation of the basivertebral nerve. Our reviewer says that the intraosseous radiofrequency ablation of the 
basivertebral nerve is not medically necessary. Our physician reviewer found that there is no magnetic 
resonance imaging (MRI) showing only modic changes without facet degenerative joint disease, and the cause 
of pain is not clear. 
 
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 intraosseous radiofrequency ablation of the basivertebral nerve have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the intraosseous radiofrequency 
ablation of the basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Osteogenesis stimulator (E0748) 
provided on June 23, 2023. 
 
You asked the Plan to waive the coinsurance for an Osteogenesis stimulator (E0748). You say that the cost 
share is wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for an Osteogenesis stimulator (E0748). This item/service falls 
within the durable medical equipment (DME) benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an Osteogenesis stimulator (E0748) provided on June 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a flexible sigmoidoscopy (45330) provided on August 31, 
2023. 
 
You asked the Plan to pay for a flexible sigmoidoscopy (45330). You say that you want the Plan to pay for the 
service. 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 a flexible 
sigmoidoscopy (45330) provided on August 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are being discharged and are unable to take care 
of yourself. The Plan denied your request. The Plan says the services you need can be provided safely in other 
settings, for example, a skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.