Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for right total shoulder replacement 
and bicep resection surgery. 
 
You asked the Plan to pre-approve inpatient admission. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested admission 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 inpatient admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo the requested elective procedure. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
Therefore, the enrollee does not meet criteria for the requested inpatient admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission for right total shoulder replacement and bicep resection surgery.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee from January 27, 2022, to January 28, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the based on the Medicare billing standards, the records provided do not support the billing of code 99285. The definition of code 99285 states this is an emergency department visit which requires these 3 key components which a comprehensive history; a comprehensive examination; and medical decision making of high complexity. The records show the enrollee was stable. No findings in lab work. No signs of multisystem dysfunction. No condition that posed an immediate life threat. No acute situation of a complex nature to support the level of care billed. No specialty consults or extensive decision making was required. No critical or extensive care was involved.
This claim was not billed with the code appropriate for the medical condition. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided to the enrollee from January 27, 2022, to January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on June 17, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the dental services. You say that you were told you could use your dentist. The Plan denied your request. The Plan says that the plan does not cover care performed outside of the United States unless it is an emergency.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that they cover worldwide services outside of the United States for emergency care and urgently needed care. Worldwide services are only coverable for emergency and urgent care. The dental services were received outside of the country for a non-emergency and non-urgent care. 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 dental services provided on June 17, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88304-TC billed for date of service October 
27, 2022. 
 
You asked the Plan to pay for procedure code 88304-TC. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88304. This means 
there is both a professional and technical component for the CPT code(s). Based on this information, we 
decided that Medicare rules for coverage of procedure code 88304 have not been met, as both the PC and TC 
have been submitted on the physician claim. It is appropriate for the physician to bill 88304-26, which has been 
paid, but 88304-TC should be billed by the facility on a separate facility claim. Therefore, we decided that the 
Plan does not have to pay for procedure code 88304-TC billed for date of service October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9273 and A6413 billed for dates of service 
July 7, 2022, and August 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the charges are appropriate for the level of 
service provided. The Plan denied your request. The Plan says the codes are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes A9273 and A6413 have a status indicator of E1. These codes are not paid when 
submitted on outpatient claims. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
A9273 and A6413 billed for dates of service July 7, 2022, and August 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found documentation shows that 
treatment goals (tolerate 35 minutes of activity, bed mobility and transfers at min A, edge of bed sitting goal) 
have all been met by most the recent physical therapy note. Thus, the records do not show that skilled therapy 
services are required to effectively provide treatment, care, and/or services in order to improve your level of 
function, or to establish/perform a maintenance program to maintain your level of function and/or prevent 
deterioration. The requested 12 additional home health physical therapy sessions are not medically necessary 
based on clinical documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve SIJ injection. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that SIJ injections are only covered for certain indications. 
 
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 SIJ injection. Our reviewer says that the 
documentation does not support that the requested injection services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has sacroiliitis documented by three physical exam findings and on 
magnetic resonance imaging. In this case there is moderate canal stenosis and foraminal stenosis present. 
Therefore, the enrollee does not 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 SIJ injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SIJ injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the reconstructive surgery for both eyelids. 
 
You asked the Plan to pre-approve the reconstructive surgery for both eyelids. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are 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 reconstructive surgery for both 
eyelids. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation that you have tried/failed conservative 
measures with artificial tears / ointment for eye irritation or that you have persistent eyelid ectropion requiring 
surgical intervention.  
  
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 reconstructive surgery for both eyelids have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the reconstructive surgery for both eyelids.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on April 16, 2022 and billed under code 99053.
You asked the Plan to pay for codes 99053 and 99291. 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 for no proof of payment on code 99291. The Plan requested a reopen and provided documentation to show code 99291 had been paid.
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 99053 has a status indicator of B on the Physician Fee Schedule.
This means that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided on April 16, 2022 and billed under code 99053.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 76641-LT and 76641-RT billed to the enrollee for date of service November 4, 2022.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and noted per the Medicare MUE Practitioner Services sheet effective July 1, 2022, code 76641 has an MUE value of 1. The MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022, update. As the date of service in question is November 4, 2022, the new MUE value of 1 would apply.
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 an issue with the MUE value for code 76641. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for codes 76641-LT and 76641-RT provided to the enrollee on November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6219, A6196, A6212 billed for date of 
service December 12, 2022. 
 You asked the Plan to pay for procedure codes A6219, A6196, A6212. You say that the service are for use at 
home. The Plan denied your request. The Plan says the procedure codes A6219, A6196, A6212 are 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 codes A6219, A6196, A6212 have a status indicator of P on the Physician Fee 
Schedule. This means that procedure codes A6219, A6196, A6212 are not separately payable. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A6219, A6196, A6212 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes A6219, A6196, A6212 
billed for date of service December 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is necessary for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services (76641) provided to the enrollee on July 26, 2022.
You asked the Plan to pay for 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 overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that per the Medicare MUE Practitioner Services sheet Effective July 1, 2022, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2 indication, this is a date of service edit.
The MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022, update. As the date of service in question is July 26, 2022, the new MUE value of 1 would apply. Per the Medicare guidelines, the Plan correctly denied the claim for payment.
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 due to the MUE value for code 76641 on the date of service. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic services (76641) provided to the enrollee on July 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport and ground mileage provided on March 12, 2022. 
 
You asked the Plan to pay for ambulance services and ground mileage. You say that you are requesting 
reconsideration of the denial of the ambulance services. The Plan denied your request. The Plan says 
ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate 
facility that can provide care if they are furnished to a member whose medical condition is such that other 
means of transportation could endanger the persons health or if authorized by the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ambulance services and ground 
mileage have been met. Specifically, the provider did not submit to the Plan the correct medical records to 
support payment of this claim. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, non-emergency transport and ground mileage provided on March 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF services provided March 10, 2022, to April 1, 2022, 
billed with PDPM FCPE1 x 22 days. 
 
You asked the Plan to pay for the SNF services as billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate PDPM. 
 
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 SNF services as billed. Our reviewer says that the 
documentation does not support the PDPM billed. Our reviewer found the enrolled received SNF services. 
There is no completed minimum data set (MDS) in the records and the submitted functional status elements of 
the MDS are undated. Therefore, PDPM of FCPE1 x 22 days is not supported 
 
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 SNF services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided March 10, 2022, to April 1, 
2022, billed with patient driven payment model (PDPM) FCPE1 x 22 days.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tracheostomy inner cannula provided on October 28, 2022. 
 
You asked the Plan to pay for tracheostomy inner cannula. You say that you are requesting the submitted 
documentation be reviewed. 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 tracheostomy inner 
cannula provided on October 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided from May 30, 2021, to July 28, 2021.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that code Q5001 must match the revenue code billed with the G code. The provider did not bill the appropriate code.
The Plan is correct in this case. 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 an error with the Q cold billed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from May 30, 2021, to July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry services (88189) provided on January 5, 
2022. 
 
You asked the Plan to pay for flow cytometry services. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 88189. Any codes which are not listed are considered not medically necessary for 
code 88189. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the flow cytometry services have not been met. Specifically, the medical records indicate that these 
services were provided for diagnoses of nasal polyp, left, excision and maxillary sinus, left, polyp, which are not among those diagnoses listed as medically necessary and appropriate for this service/code. Therefore, we 
decided that the Plan does not have to pay for flow cytometry services (88189) provided on January 5, 2022.