Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of excess skin on stomach (15830 and 
15847). 
 
You asked the Plan to pre-approve the surgical services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 surgical services. Our physician 
reviewer found there is no documentation that the abdominal lipectomy/panniculectomy at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the enrollee. The provided records in 
this case document the enrollee had a laparoscopic gastric bypass surgery on April 25, 2022. The provided 
records in this case do not document at least 18 months have passed since the bariatric surgery. 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 surgical services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the removal of excess skin on stomach (15830 and 15847).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no required medical services identified that are available at the LTACH, 
that are not available at the current health care setting being offered/provided by the Health Plan. 
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services billed to the enrollee under code 76641 for services provided on September 6, 2022.
You asked the Plan to pay for this claim. 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 noted that per the Medicare Medically Unlikely Edits (MUE) Practitioner Services sheet Effective July 1, 2022, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2. Please note that 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 September 6, 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. Providers must report services with the appropriate code. In this case, this claim could not be paid due to a change in the MUE value of the code. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for imaging services billed to the enrollee under code 76641 for services provided on September 6, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 14,
2022 and billed under code 76641.
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 The Plan noted that per the
Medicare Medically Unlikely Edit (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. Please
note that 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 October 4, 2022, the new MUE value of 1 would apply.
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 due to an
issue with the MUE status of the code reported. Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on
October 14, 2022 and billed under code 76641.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for ultrasound services provided to the enrollee on October 3, 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 are reopen and provided additional information. The Plan notes that per the Medicare Medically Unlikely Edit (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 Plan notes 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 October 3, 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. Providers must report services with the appropriate codes. In this case, this claim could not be paid as billed due to the MUE value attached to the claim 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 ultrasound services provided to the enrollee on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from June 11, 2022, to June 12, 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 for insufficient claim information.
The Plan requested a reopen and provided additional claim information. The Plan submitted the claim that was previously paid for these services. The Plan also submitted claims that were sent in between June 11, 2022, to June 12, 2022, from the provider for the same services that still denied. The records submitted do not indicate that two separate services were performed or supported. The provider was previously paid for the services billed. The claims processing systems contain edits which identify exact duplicate claims and suspect duplicate claims.
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, the Plan has provided documentation to show these services were previously billed and paid. Medicare rules for coverage of this appealed claim are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from June 11, 2022, to June 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional power wheelchair accessories (K0108 and E2311).
You asked the Plan to provide coverage for these accessories. You say that at the time of the appeal, these accessories were medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes a K0108, the transit option, is not covered as it is primarily for use outside of the home to attach the unit to a vehicle. The expandable controller with harness (E2311) is not needed for the operation of the wheelchair base. The expandable controller with harness (E2311) is only needed if the user cannot flip a switch to operate the requested power option of tilt. The records show the enrollee can feed, groom, bath and toilet independently and therefore would have no trouble activating switches to control the power options.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not cover accessories used outside of the home. Medicare does not cover the transit option (K0108). The records show the enrollee does not meet the criteria required for the E2311 for expandable controller with harness. Therefore, we decided that the Plan does not have to provide coverage for additional power wheelchair accessories (K0108 and E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 11, 2022, under code 64999.
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 for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that this is an administrative determination for incorrect coding and is not based on clinical criteria for medical necessity. The enrollee underwent bilateral, imaging-guided, single-level lumbar vertebral blocks for post-op pain management on August 11, 2022, prior to lumbar surgery. Medicare guidance says that procedures should be reported with the most comprehensive code that describes the services performed. An unlisted code shall be used only if the service is not accurately described by other HCPCS/CPT codes. The service was billed with an unlisted code of 64999. Code 64493, injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level, more accurately describes the procedure performed. Additionally, modifier -50 for a bilateral procedure, would be appended to the code as the block was documented as both left and right.
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 code 64999 and the omission of a required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 11, 2022, under code 64999.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 25, 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 unique test identifier or DEX-Z code was not submitted on the claim. Maximus overturned the Plans denial stating the wrong Medicare regulation was used. The Plan requested a reopen and provided additional information to show the service was performed in the jurisdiction which requires this particular test identifier 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 codes. In this case, this claim could not be paid as billed due to an omission of the required unique test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 25, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 4, 2022 and coded as 76641.
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 Medically Unlikely Edit (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. Please note that 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 October 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. Providers must report services with the appropriate code. In this case, this claim could not be paid due to an error with the MUE value of 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 imaging services provided to the enrollee on October 4, 2022 and coded as 76641.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (codes 00860 and 99100) provided to the enrollee on March 2, 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 partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan notes that review of code 00860 denied correctly per Medicare Claims Processing Manual Chapter 12 - Physicians and Non-physician Practitioners, Section 140.3.3. This section of the manual states; "The following modifiers are used by qualified nonphysician anesthetists when billing for anesthesia services":
- QX - Qualified nonphysician anesthetist service: With medical direction by a physician. - QZ - CRNA service: Without medical direction by a physician. - QS - Monitored anesthesia care services.
The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes. Providers must report actual anesthesia time and one of the payment modifiers on the claim.
Payment for Anesthesiology Services, Section 5- "I" also states: Physicians report the appropriate modifier to denote whether the service meets the requirements for payment at the personally performed rate, medically directed rate, or medically supervised rate:
AA - Anesthesia Services performed personally by the anesthesiologist AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedures G9 - Monitored anesthesia care for patient who has a history of severe cardio- pulmonary condition QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals QS - Monitored anesthesia care service NOTE: The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes. Providers must report actual anesthesia time and one of the payment modifiers on the claim. QY - Medical direction of one qualified nonphysician anesthetist by an anesthesiologist GC - These services have been performed by a resident under the direction of a teaching physician.
As the provider billed anesthesia code 00860 and failed to list any modifier on the claim, the Plan denied correctly.
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 omission of the required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (codes 00860 and 99100) provided to the enrollee on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral imaging (D0220) and palliative treatment (D9110) provided on October 6, 2022.
You asked the Plan to pay for these dental services. The Plan denied your request. The Plan says code D0220 was previously exhausted and code D9110 is not a covered benefit. Maximus partially overturned the Plans denial for a lack or paid services in the file. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. Medicare generally does not cover dental services. 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, code D9110 is not a covered benefit and code D0220 was exhausted on September 21, 2022. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220) and palliative treatment (D9110) provided on October 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan 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 medical records the enrollee's show ability to participate in intensive therapy very limited by the hospital physical therapist. The enrollee had no bilateral lower extremity strength, decreased endurance and spasms in all four extremities. The enrollee required a Hoyer lift as she was non-ambulatory. There was no indication in the medical records that the enrollee would make measurable improvement given the chronic weakness, spasticity, and contractures. Medicare coverage criteria for IRF admission were not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an EWheels Portable Lightweight travel mobility scooter.
You asked the Plan to provide coverage for this equipment. You say that at the time of the appeal, this equipment was medically necessary for mobility in the home. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that there is no home evaluation to show the requested power mobility device is appropriate for your home.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that a power scooter will not be covered without a home evaluation showing your home can accommodate the use of this type of device. Specific documentation of a home evaluation should be included in the documentation. The records submitted by your provided does not include an appropriate home evaluation. Medicare rules for coverage of the requested scooter are not met. Therefore, we decided that the Plan does not have to provide coverage for an EWheels Portable Lightweight travel mobility scooter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 23, 2021.
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 records submitted show the specimens were collected on November 1, 2021, and December 6, 2021. The provider billed 81479 with date of service (DOS) December 23, 2021, and Place of Service (POS) 81. The claim listed the place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office contradicting the reasoning that the specimen was collected in a hospital. The exceptions to the General Rule do not apply as the provider documented on the claim form that the specimen was obtained by the laboratory directly and not collected from a hospital outpatient during an encounter. Medicare rules state if an independent lab bills for services, the place where the sample was taken is shown. POS code 81 is used to describe samples taken by the laboratory directly.
An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively.
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 place of service code. In this case, this claim cannot be paid as billed due to an error with the reported place of service code. 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 lab services provided to the enrollee on December 23, 2021.