Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97813, 97814) provided from October 
15, 2022, to November 12, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that these services have been approved and paid 
for other dates of service. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, medical documentation has not been provided to 
document that your low-back pain is chronic, non-specific and not associated with either surgery or pregnancy. 
Therefore, we decided that the Plan does not have to pay for acupuncture services (97813, 97814) provided 
from October 15, 2022, to November 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AngelMed Guardian System. 
 
You asked the Plan to pre-approve AngelMed Guardian System. You say that the enrollee would benefit from 
placement of this device which is a predictor of acute coronary syndrome (ACS) events when compared to 
patient recognized symptoms alone. The Plan denied your request. The Plan says this device is unproven for 
safety and efficacy. 
 
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 AngelMed Guardian System. Our 
reviewer says that the requested AngelMed Guardian System is not considered medically reasonable and 
necessary in this case. Our physician reviewer found an exhaustive review of the current medical literature 
pertaining to the AngelMed Guardian system confirms several observational studies suggesting clinical benefit. While the clinical studies led to Food and Drug Administration (FDA) approval, the AngelMed Guardian 
system remains the subject of studies assessing long-term efficacy, as well as randomized, controlled, blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. Therefore, the reviewer found that the requested AngelMed Guardian 
System is not medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of AngelMed Guardian System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve AngelMed Guardian System.
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 an IRF admission is needed for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not met the requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support the need for an IRF admission. The enrollee can receive further services at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lntracept procedure. 
 
You asked the Plan to pre-approve the lntracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for patients suffering from chronic low back pain. You say 
that the peer-reviewed literature clearly supports your request. The Plan denied your request. The Plan says the 
lntracept procedure 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 lntracept procedure. Our reviewer 
says that the requested lntracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the lntracept procedure is considered experimental/investigational at this 
time. Therefore, the request is deemed not medically reasonable and 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 the lntracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the lntracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthotic shoe inserts.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve orthotic 
shoe inserts.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
without the appropriate secondary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should report the most appropriate 
ICD-10 code that adequately describes the patients medical condition at the time of transport as the primary 
diagnosis. In addition, a secondary diagnosis, from ICD-10 Code Group 3 below, must be reported. 
 
We looked at the file and Medicare rules. The claim in this case was not billed with an appropriate secondary 
diagnosis code as required by LCA A54574. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services provided on January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toilet rail. 
 
You asked the Plan to pre-approve a toilet rail. You say that you would like reconsideration because the 
requested toilet rail is medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that toilet rails are not covered because 
they are not primarily medical in nature.  
 
While a toilet rail may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a toilet rail.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97597, 99203, and 15271 billed for date of 
service June 2, 2022, to September 8, 2022.  
 
You asked the Plan to pay for procedure codes 97597, 99203, and 15271. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. Medicare rules also say that claims submitted where the unit of service exceeds the MUE value cannot be 
paid when the MAI value is 2. 
 
In this case, the MUE for CPT code 97597 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. In this case, the MUE for CPT codes 
99203 and 15271 is 1 The MAI value for this code is 2. You billed 2 units of each of these codes, exceeding the 
MUE. Based on this information, we decided that Medicare rules for coverage of procedure codes 97597, 
99203, and 15271 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 97597, 99203, and 15271 billed for date of service June 2, 2022, to September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ca-Rezz No Risc Skin cream Aloe vera lotion. 
 
You asked the Plan to pre-approve the Ca-Rezz No Risc Skin cream Aloe vera lotion. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this item does not primarily serve a medical 
purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the Ca-Rezz No Risc Skin cream Aloe vera lotion.
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 intense multidisciplinary team is essential to 
identify and establish a base functional platform that will drive further recovery, reduce risk of medical and 
functional regression, and mitigate the risk of returning to acute hospitalization. The Plan denied your request. 
The Plan says the IRF services requested 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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 pay for the services (73110, 99024, A4590) provided on May 17, 
2023. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
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 payment for CPT code 73110 is not supported in the medical record. Specifically, code 73110 was 
not billed with the required anatomic modifier. Based on this information, we decided that Medicare rules for 
coverage of code 73110 have not been met. 
 
We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. 
 
We find that procedure code A4590 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A4590 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services (73110, 99024, A4590) provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 10, 2023, billed with 
codes 87633, 87634, 87486, 87498, 87502, 87581, 87640, 87651, 87798, and U0005. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
May 10, 2023, billed with codes 87633, 87634, 87486, 87498, 87502, 87581, 87640, 87651, 87798, and 
U0005.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for an enteral-nutrition infusion pump (B9002) provided on April 22, 2023.

You asked the Plan to pay for an enteral-nutrition infusion pump. You say that you have billed the item at issue correctly. The Plan denied your request. The Plan says that the item at issue has been reported with an incorrect Place of Service (POS) code.

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 item was billed with a POS code indicating that it was provided in a nursing facility. The Plan states that the item at issue is not a valid service when provided at a nursing facility. However, the rule cited by the Plan explicitly does not exclude the item at issue from coverage when provided at a nursing facility. It is the Plan's responsibility to support its denial with evidence. In this case, the Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for an enteral-nutrition infusion pump (B9002) provided on April 22, 2023.

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 pre-approve the breast cancer 1 and breast cancer 2 genetic testing 
(81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that your doctors are all in agreement that this 
test is medically necessary due to your extensive family history of cancer and previous diagnosis that put you at 
high risk for cancer. The Plan denied your request. The Plan says the Medicare medical necessity criteria are 
not met as per LCD. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per the records provided the enrollee does not have a personal history 
of cancer. 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 breast cancer 1 and breast 
cancer 2 genetic testing (81162).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from December 2, 2022, to December 
14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is a more 
appropriate code for these services. 
 
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 97535 is "Self-care/home management training (eg, 
activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and 
instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 
minutes". 
 
We find that CPT code 97535 is not supported in the medical record. Specifically, there is a more appropriate 
code for the home therapy services provided in this case. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services provided from December 2, 2022, to December 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance transport provided on December 3, 2021.

You asked the Plan to pay for this transport. You say that this claim should be paid. 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/
demonstrated that the Medicare Fact Sheet for Ambulance Suppliers and Providers (Participants) states the ET3
Model applies only to the traditional Medicare Fee-for-Service program and does not apply to Medicare
Advantage (MA) plans. Model payments for transport to an Alternative Destination and Treatment in Place
interventions will be made available for Medicare Fee-for-Service beneficiaries only. The "RW" modifier is
solely used for the ET3 Model and is not valid for this Medicare Advantage claim.

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 the enrollee codes submitted
and the enrollee being a member of an MA plan. Medicare rules for coverage of this transport have not been
met. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee
on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for dental services coded as D0610 and D6104.

You asked the Plan to provide coverage for these services. The Plan denied your request. The Plan says these
are not services covered under the dental benefit. Maximus overturned the Plans denial because a Plan contract
was not submitted for review. The Plan requested a reopen and submitted the required Plan contract.

The Plan is correct in this case. Medicare 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the services are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to provide coverage for dental
services coded as D0610 and D6104.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
May 23, 2023. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. 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 the 
urine polymerase chain reaction (PCR) panel rendered on May 23, 2023.