Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation with a medicinal agent - per quadrant 
(D4921) provided on June 5, 2023. 
 
You asked the Plan to pay for the gingival irrigation. You say that you do not agree with the denial of the 
dental services. The Plan denied your request. The Plan says this is not a covered service under your plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation with a medicinal agent - per quadrant (D4921) provided on June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve block (64454) provided to the enrollee on January 20, 2023.
You asked the Plan to pay for the genicular nerve block. You say that the documentation supports the charges. The Plan denied your request. The Plan says the documentation supports the charges. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Local Coverage Article states that procedure code 64454 is only covered for certain diagnosis codes. The claim was not billed with one of the necessary diagnosis codes. Based on this information, we decided that Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block (64454) provided to the enrollee on January 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that records have been submitted to show medical 
necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found an electromyography (EMG) has been 
planned but not yet done. The neurological exam is negative. There is no contraindication to a 6-week trial of 
physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 5, 2022.
You asked the Plan to pay for procedure code 99100. You say that this should be paid as billed. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service January 16, 2023.
You asked the Plan to pay for code J3490. You say that the drug was a necessary part of the enrollee's treatment. The Plan denied your request. The Plan says that the code is included in the global surgery period of minor procedure code 20610. Maximus overturned the Plan's denial stating the code was valid. The Plan requested a reopen and demonstrated that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 20610 that was billed on the same claim.
Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service. Per the above Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service.
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, payment for code J3490 in this case was included in the payment for the administration and infusion services. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service January 16, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the cardiac stress test and regadenoson injection provided on November 15, 2022.
You asked the Plan to waive the cost-sharing for the cardiac stress test and regadenoson injection. You say that you were not told ahead of time about these costs. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for Medicare-covered Nuclear Medicine at a freestanding provider or at an outpatient hospital setting and a 20% coinsurance for Part B medications and contrast agents injected during the service or Part B medications topically applied during the service. You have been asked to pay a $75 copayment for the cardiac stress test and a 20% coinsurance for the regadenoson injection. This cardiac stress test falls within the Medicare-covered Nuclear Medicine at a freestanding provider or at an outpatient hospital setting and the regadenoson injection falls within the Part B medications and contrast agents injected during the service or Part B medications topically applied during the service 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 cost-sharing for the cardiac stress test and regadenoson injection provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311) and power seat elevation feature (E2300).
You asked the Plan to pre-approve an expandable controller, harness, electronic connection and power seat elevation feature. You say that these items are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control the multiple power options through the joystick and that the seat lift feature is not medical in nature and therefore not covered.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller, harness and electronic connection. Our Medical Director states that provided records document that you have 5/5 left upper extremity strength and is independent with eating thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. Our Medical Director found that your condition does not meet criteria for coverage of an expandable controller, harness and electronic connection. We looked at this physician's review, the file, and Medicare rules. A power seat elevation feature is non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness, electronic connection and power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311) and power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311) and power seat elevation feature (2300) for the enrollee.
You asked the Plan to pre-approve an expandable controller, harness, electronic connection and power seat elevation feature. You say that these items are medically necessary for the enrollee. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller, harness and an electronic connection. Our Medical Director states that the provided records document that the enrollee has 3-/5 to 3+/5 upper extremity strength and is independent with eating and grooming thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage for an expandable controller, harness and an electronic connection. We looked at this physician's review, the file, and Medicare rules. Medicare rules state that a power seat elevation feature is non-covered because it is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness, electronic connection and power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311) and power seat elevation feature (2300) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 95822 and 95927 provided to the enrollee on April 20, 2022.
You asked the Plan to pay for procedure codes 95822 and 95927. You say that this should be paid for. The Plan denied your request. The Plan says that the records do not support the services billed. Maximus reopened this case because we found the incorrect decision template was used and the wrong decision was rendered.
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 95822:
Electroencephalogram (EEG); recording in coma or sleep only
CPT 95927:
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites,
recording from the central nervous system; in the trunk or head 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 procedure codes 95822 and 95927. Our reviewer says that in terms of the technical report does indicate that an EEG was performed. However, this code is not supported as the enrollee was not in a coma or sleep. There are more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). Therefore, the records do not support that CPT 95822 was rendered. In terms of CPT 95927, the technical report cites recording sites for the SSEP (somatosensory evoked potential) were the ulnar nerve and posterior tibial. Neither of these would be in the trunk or head. Therefore, records do not support that CPT 95927 was rendered. Our reviewer found that the services at issue in this case were not supported by the medical records. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure codes 95822 and 95927 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95822 and 95927 provided to the enrollee on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for services billed for inpatient care provided to the enrollee from July 29, 2021, to September 29, 2021.
You asked the Plan to pay for this claim as billed. You say that you disagree with the Plan's denial. The Plan says this claim could not be paid as billed due to billing errors and inconsistency with the medical records. The Plan states the denied charges were due to items that were billed which are not allowed to be paid separately. Maximus overturned the Plans denial for missing documentation in the case file. The Plan requested a reopen and provided the required documentation. The Plan notes that once the itemized bill was received it was determined several items and services were identified as routine items and services inclusive to either room and board or included in the payment of a procedure, and therefore are not separately billable. The Plan upheld the denial of these routine items and services in the amount of $7,513.70. The Plan submitted the Itemized Bill Summary of denied charges.
The Plan noted the Facility recently provided the itemized bill allowing the Plan to identify and validate the charges utilizing both the itemized bill and medical records. Ultimately the Plan upheld denied charges in the total amount of $7,513.70 and approved total charges in the amount of $237,276.74.
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 codes. In this case, review of the itemized bill and the itemized summary shows those codes that were denied by the Plan were done so because their payment is included in the payment of another code and therefore cannot be billed separately. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for services billed for inpatient care provided to the enrollee from July 29, 2021, to September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DEXCOM G7 receiver null device.
You asked the Plan to pre-approve a DEXCOM G7 receiver null device. You say that your transmitter is not working correctly, and you need another one early. The Plan denied your request. The Plan says that there is no evidence that the member's current continuous glucose monitor (CGM) receiver is not functioning as it should. Maximus overturned the Plan's denial based on medical necessity.
The Plan requested a reopening and stated that this was not upheld based on medical necessity but because the enrollee already has a working CGM. The Plan is correct in this case. The file indicates you received a DEXCOM G6 on February 19, 2023. In this case a DEXCOM G7 would be a device that serves the same purpose as a DEXCOM G6. You also received the DEXCOM G6 less than five years ago, so you are still within the reasonable useful lifetime and cannot receive a replacement device. Therefore, we decided that the Plan does not have to pre-approve a DEXCOM G7 receiver null device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
February 3, 2023, to March 4, 2023. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the device is Food and 
Drug Administration (FDA) approved and is considered an essential health benefit which makes the charges 
eligible for coverage. The Plan denied your request. The Plan says the requested device is not a covered 
benefit. 
 
 The Plan must follow Medicare rules. Medicare rules say that it has not been established that a water 
circulating heat pad with pump (E0217) is reasonable and necessary compared to a standard electric heating 
pad (E0210); therefore, if code E0217 is provided it will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Specifically, Medicare rules has denied 
the requested device as it is not reasonable and/or necessary. Therefore, we decided that the Plan does not have 
to pay for a water circulating heat pad with pump (E0217) provided on February 3, 2023, to March 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311), non-expandable 
controller replacement (E2375), and remote joystick replacement (E2374). 
 You asked the Plan to pre-approve upgraded electronics (electronic connection), joystick and non-expandable 
controller. You say that the items are medically necessary. The Plan denied your request. The Plan says 
upgraded electronics cannot be covered as there is not a medical need to control the requested power options 
through the joystick. The joystick and non-expandable controller are part of the already approved wheelchair 
base. These cannot be requested separately.  
 
The Plan follows Medicare rules. Medicare rules say that items 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 upgraded electronics (electronic 
connection), joystick and non-expandable controller. Our reviewer says that the items are not medically 
necessary. Our physician reviewer found the enrollee has adequate upper body strength to control the standard 
power switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics (electronic connection), joystick and non-expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic 
connection (E2311), non-expandable controller replacement (E2375), and remote joystick replacement 
(E2374).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine transportation trip provided on May 9, 2023.  
You asked the Plan to pay for the transportation trip. You say that you had to resort to a person who is 
dedicated to making private transportation. You also say that you had to pay $75 for the service since the 
transportation service you had coordinated was cancelled. The Plan denied your request. The Plan says the 
service provider is not incorporated and is not contracted with the Plan. The Plan also says no pre-authorization 
was done. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when unlimited one-way transportation trips to plan approved 
health-related locations per year, such as appointments with a physician, to receive medical treatments, for 
medical procedures and/or to obtain results of medical/ laboratory studies and medications. Authorization rules 
may apply.  
 
We looked at your request, the records in the case file, and the rules. You asked the plan to pay for the routine 
transportation trip. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
transportation trip provided on May 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment services with no 
transport provided on March 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment services with no transport. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there is 
no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment services 
with no transport provided on March 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 1, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you experienced a fall 
in your home and were unable to get up without assistance. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on May 1, 2023.