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

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record provided does not indicate that the treating physician has a 
reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical 
factors. The initial day may be spent in observation until it is clearly expected that a second midnight would be 
required, at which time the physician may order 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unoccupied tiedown deluxe contour seats (K0108). 
 
You asked the Plan to pre-approve tiedown deluxe contour seats. You say that the enrollee has had a change in 
weight and needs the requested wheelchair. The Plan denied your request. The Plan says the deluxe contour 
seats are not durable medical equipment and are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve unoccupied tiedown deluxe contour seats (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided to the enrollee on October 15, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that this claim was billed correctly. The Plan denied your request. The Plan says that you did not submit any evidence that they have been contacting the member before shipping additional supplies. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the electrodes begin dispensed. Based on this information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided to the enrollee on October 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of a root canal obstruction; non-surgical 
access (D3331). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
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 pre-approve the 
treatment of a root canal obstruction; non-surgical access (D3331).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from March 7, 2023, to March 9, 2023. 
 
You asked the Plan to pay for SNF care. You say that you are requesting a reconsideration for the dates in 
question. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for SNF care provided from March 7, 2023, to March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
request reconsideration due to medical necessity. The Plan denied your request. The Plan says upgraded 
electronics cannot be covered per Medicare rules. They are necessary when there is a medical need to control 
power options though the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has tetraplegia. He is able to perform personal hygiene and weight shift 
with a trapeze. Per SSA 1862 (a) 1 (A), the enrollee has adequate upper body strength to manage standard 
power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups (D2950 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are necessary for a better 
long-term prognosis. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildups (D2950 x 4).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 0245U provided to the enrollee on August 9, 2022.
You asked the Plan to pay for procedure code 0245U. You say that these services were necessary and are supported in the medical record. The Plan denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U.
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 0245U is a column II code to column I code 0018U. 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 0245U provided to the enrollee on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. The Plan denied your request. The Plan says 
this item is unfortunately not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit supplies provided to the enrollee on August 29, 2022.
You asked the Plan to pay for the TENS unit supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says that since the provider is renting the TENS Unit to the member the provider should not bill for supplies. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. Therefore, this claim was 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, the provider is billing for supplies separately for rented equipment, which is not allowed. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the TENS unit supplies provided to the enrollee on August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae BRCA 1/2 panel (81433) provided on March 6, 
2023. 
 
You asked the Plan to pay for the Invitae BRCA 1/2 panel. You say that this test was medically necessary. The 
Plan denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process 
 
We looked at the file and Medicare rules. The DEX database shows that this test is not covered. Based on this 
information, we decided that Medicare rules for coverage of the Invitae BRCA 1/2 panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the Invitae BRCA 1/2 panel (81433) provided on 
March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 9, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says that since the provider is renting the TENS Unit to the member the provider should not bill for supplies. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The provider is billing the units in excess of the Medicare allowed amount. Therefore, this claim was 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, the provider is billing for supplies separately for rented equipment, which is not allowed. The provider is also billing in excess of the normal units allowed by the billing guidelines. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for procedure code 87798. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
with the units/codes reported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 pay for procedure code 87798 Our reviewer says 
that the units reported for this code are not supported by the records provided. Our physician reviewer found 
according to CPT rules, some of the organisms can be reported with their own specific CPT code and should 
not be reported as not otherwise specified. The record supports only 8 units of 87798 in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87798 billed for date of service February 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 1, 
2023,to January 16, 2023. 
 
You asked the Plan to pay for SNF care. You say that you feel a skilled nursing facility is medically necessary. 
The Plan denied your request. The Plan says the enrollee's condition no longer required a skilled nursing 
facility level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from January 1, 2023,to January 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 40 occupational therapy visits for the enrollee.
You asked the Plan to pre-approve the therapy services. You say that the enrollee has shown improvement, but their therapy goals have not been met. The Plan denied your request. The Plan says that the records provided do not support the request for treatment.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for 40 occupational therapy visits. Our Medical Director states that while skilled therapy is generally accepted as effective therapy for the enrollee's condition, the available clinical documentation does not support that 40 OT visits were medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 40 occupational therapy visits. 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 therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve 40 occupational therapy visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81201, 81307, 81321, 81351, 81403, 81404, 
81405, 81406, and 81479) provided on January 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 (81201, 81307, 81321, 81351, 81403, 81404, 81405, 81406, and 
81479) provided on January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for a Freestyle Libre 3 continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the sensors. You say that you would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says that this is not covered by Medicare. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor (CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and assigned code E2103 may be billed using this code. We looked at the file and Medicare rules. The request at issue is for a supply for the Freestyle Libre 3 non-adjunctive CGM. However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does not have to pre-approve sensors for a Freestyle Libre 3 continuous glucose monitor for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the nuclear medicine heart study and drug injection provided on October 10, 2022.
You asked the Plan to waive the cost-sharing for the nuclear medicine heart study and drug injection. You say that you received prior approval for these services. 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 $375 copayment for in-network diagnostic radiology and a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $375 copayment for the nuclear medicine heart study and a 20% coinsurance for the drug injection. The nuclear medicine heart study falls within the in-network diagnostic radiology and the drug injection falls within the Medicare Part B prescription drugs 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 nuclear medicine heart study and drug injection provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J7613 and J7644 billed for date of service 
October 5, 2022.  
 
You asked the Plan to pay for procedure codes J7613 and J7644. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes J7613 and J7644 is 0 when provided in a facility setting. The MAI value 
for this code is 3. You billed greater than 0 units of each of these codes, exceeding the MUE. You did not 
provide all the required evidence showing that the excess units were actually provided, were correctly coded, 
and were medically necessary. Based on this information, we decided that Medicare rules for coverage of 
procedure code J7613 and J7644 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes J7613 and J7644 billed for date of service October 5, 2022.