Persius/hicric huggingface dataset:
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the request is not medically necessary. Maximus overturned the Plan's
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The records
clearly show that at the time of the appeal prior to admission the enrollee did not meet all the criteria required
by Medicare for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service August 21, 
2023. 
 
You asked the Plan to pay for procedure code 20930. You say that you believe this is a separately reimbursable 
service. The Plan denied your request. The Plan says procedure code 20930 is considered bundled and not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on May 02, 2023. 
 
You asked the Plan to pay for an outpatient visit. You say that you are requesting reconsideration for 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 an outpatient visit 
provided on May 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to cover the cost for an out-of-network dermatology visit provided on 
August 18, 2023. 
 
You asked the Plan to cover the cost for a dermatology visit. You say that you want this to be covered by your 
Plan. 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 $625 deductible which applies to physician/practitioner services, 
including doctors office visits. You have been asked to pay $143.50 towards this deductible. 
 
The item or service you asked the Plan to cover the cost for falls within the physician/practitioner services, 
including doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $625 deductible which applies to physician/practitioner services, including doctors 
office visits. This cost sharing is a contractual obligation that had not been met at the time a dermatology visit 
was received on August 18, 2023. Therefore, we decided that the Plan does not have to cover the cost for an 
out-of-network dermatology visit provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99291 rendered on May 2, 2023, 
and May 3, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services are not supported without the required 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 the denied codes is: 
 
CPT 99233: 
 
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 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee has diabetes, 
hypertension, and neuropathy, and presented to the emergency department (ED) with back pain. The enrollee 
was found to have severe constipation and was noted to be in atrial fibrillation. The enrollee was admitted and 
placed on a Cardizem drip, and was then transitioned to oral Cardizem, and then Amiodarone. The enrollee was 
admitted on 5/2 and discharged on 5/4/23. Only a discharge summary is provided, and the documentation does 
not support either 99233 or 99291. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99233 and 99291 rendered on May 2, 2023, and May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental code D9230 provided on February 2, 2023.

You asked the Plan to pay for these dental services. It has now been confirmed by the Plan that codes D7140,
D7210 and D7250 were paid prior to the case being sent to Maximus. The Plan states code D9230 is not a
covered service under the Plan dental benefit.

The Plan is correct in this case. Medicare does not cover routine dental services. In 2023, the Plan offered a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offered a dental benefit in excess of Medicare coverage, code D9230 was not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental code D9230
provided on February 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination of the shoulder provided on July 31, 
2023. 
 
You asked the Plan to pay for radiologic examination of the shoulder. You say that the 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 radiologic examination 
of the shoulder provided on July 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim.  

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 85025) related to ESRD 
provided on July 11, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed.  
  Therefore, we decided that the Plan does not have to pay for the laboratory services (80053, 85025) related to 
ESRD provided on July 11, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral sacroplasty. 
 
You asked the Plan to pre-approve sacroplasty. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 sacroplasty. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has history of compression fractures as well as recent magnetic resonance imaging 
on December 11, 2023, showing increased T2 signal in each hemi sacrum consistent with sacral insufficiency 
fractures which produce significant pain and interruption of daily activities. The requested procedure is often 
done for sacral insufficiency fracture and is known to often be of benefit in the relief of pain. The enrollee has 
attempted extensive conservative measures including over six weeks of physical therapy without relief. The 
enrollee has debilitating pain and evidence of bilateral sacral insufficiency fractures. Therefore, the enrollee 
does meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroplasty have been met. Therefore, we decided that the Plan has to pre-
approve bilateral sacroplasty.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service April 20, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider for procedure code 87491. Without a record 
showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure code 87640 billed for date of service 
April 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard Liquid (90283). 
 
You asked the Plan to pre-approve Gammagard Liquid. You say that this is medically necessary for the 
enrollee's treatment for nonfamilial hypogammaglobulinemia. The Plan denied your request. The Plan says 
according to the provided medical records, the drug is being pharmacy dispensed to the member. The records 
we have indicate that this drug is to be given in the home and for the given indication, is a Part D Medication. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gammagard Liquid (90283).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system.  
 
You asked the Plan to pre-approve the sprint PNS system. You say that the sprint PNS system will be used to 
assess the enrollee's suitability for a permanent PNS implant. The Plan denied your request. The Plan says the 
sprint PNS system 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 sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
device is considered experimental for chronic pain, and more research is needed. 
 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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) provided on May 18, 2023. 
 
You asked the Plan to pay for validity testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing (83789) provided on May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee suffers from chronic 
vertebrogenic low back pain. You say that the enrollee has not responded to physical therapy, anti-
inflammatory, neuropathic medications, and lumbar medial branch blocks. The Plan denied your request. The 
Plan says the Intracept 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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet joint degenerative disease or 
stenosis, and the cause of pain is not clear. Therefore, the enrollee does not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 16, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service January 13, 
2023. 
 You asked the Plan to pay for procedure code 87640. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87640 billed for date of service January 13, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on September 7, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
September 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on October 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
October 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 08, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the 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 September 08, 2023.