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

 
We decided that the Plan does not have to pre-approve a Medtronic allograft (20930). 
 
You asked the Plan to pre-approve a Medtronic allograft. You say that without this procedure the enrollee's 
condition will worsen. The Plan denied your request. The Plan says this graft 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 a Medtronic allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies 
are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Medtronic allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Medtronic allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tie down kit (K0108), a power seat evaluation feature 
(E2300), and a power standing feature (E2301). 
 
You asked the Plan to pre-approve a tie down kit, a power seat evaluation feature, and a power standing 
feature. You say that you are requesting reconsideration of the denied authorization. The Plan denied your 
request. The Plan says the power seat evaluation and power standing features do not service a medical purpose. 
The Plan also says that a tie down kit is for use in transportation and not for home use. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that Medicare will pay for durable medical equipment that is needed for 
use in the home.    
 
A power seat elevation and power standing feature do not serve a purpose that is primarily medical in nature. 
The requested tie down kit is for transportation use not for home use. Therefore, we decided that the Plan does 
not have to pre-approve a tie down kit (K0108), a power seat evaluation feature (E2300), and a power standing 
feature (E2301).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 25, 2022, and coded as 76937 and 93010.
You asked the Plan to pay for lab services. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and demonstrated that while codes 99291 and 36556 were paid, code 76937 was denied as the claim was submitted without the required preceding procedure code.
The Plan must follow Medicare rules. The rules say that providers must report services correctly. Providers must report services with the appropriate code. Regarding code 93010, this is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to bypass the edit. Regarding code 76937, this code could not be paid due to the omission of a required procedure code. Medicare rules for coverage of codes 93010 and 76937 were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 25, 2022, and coded as 76937 and 93010.
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 the accessories are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet approval for the requested 
wheelchair accessories. 
 
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 multiple sclerosis. She is reported to have 3-/5 strength in her upper 
extremities, but she is independent in feeding and grooming. Per Social Security Administration (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 provided on March 11, 2023. 
 
You asked the Plan to pay for procedure code 85060. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an 
outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for procedure code 85060 provided on March 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and pontic (D2950, D6245) provided 
on March 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 pay for core 
buildup services and pontic (D2950, D6245) provided on March 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital care beyond February 25, 
2023.  
 
You asked the Plan to pre-approve inpatient psychiatric hospital care. You say that you are appealing the 
denial. The Plan denied your request. The Plan says the request for psychiatric inpatient hospital level of care 
for this admission is not medically necessary as of February 25, 2023. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital care. Our 
reviewer says that extended inpatient psychiatric care is not medically necessary. Our physician reviewer found 
that based upon review the records provided, the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of February 25, 2023, and could have been 
treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and 
compliant while not showing any acute threats to safety. 
 
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 psychiatric hospital care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital care beyond February 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric services provided on January 21, 2023, 
to January 27, 2023.  
 
You asked the Plan to pay for the inpatient psychiatric services provided on January 21, 2023, to January 27, 
2023. You say that the records provided support the need for the inpatient psychiatric services provided.  The 
Plan denied your request. The Plan says the inpatient psychiatric services provided up until January 20, 2023, 
are being approved for crisis stabilization and consolidation of treatment gains. However, as of January 21, 
2023, the stay is being denied for the patient not meeting inpatient psychiatric hospitalization criteria.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 the inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on January 13, 2023, with Schizophrenia. Based upon 
review the records provided it was not expected this enrollee would improve in a reasonable period of time for 
the dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. The 
enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question as she did not have dangerousness to self or others and 
was compliant with her treatment. It did not appear that the services were reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis beyond the date in question. This enrollee was treated 
under an individualized treatment plan found in the record. It did appear that the records were supervised and 
evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not 
meet the criteria for January 21, 2023, forward as this enrollee was not shown to be a danger to herself or 
others, delusions, auditory or visual hallucinations noted. She was cooperative/compliant with treatment while 
not showing any threats the safety. 
 
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 inpatient psychiatric services have not been met. Therefore, we decided that 
the Plan does not have to pay for inpatient psychiatric services provided on January 21, 2023, to January 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified adjunctive procedure (D9999). 
 
You asked the Plan to pre-approve an unspecified adjunctive procedure (D9999). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this service is not covered 
under your benefit package. 
 
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 an 
unspecified adjunctive procedure (D9999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided to the enrollee on April 7, 2022, and billed under code 51990.

You asked the Plan to pay for code 51990. Please note the prior decision letter noted 55899 to be the code under appeal which was incorrect. . 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 code 55899. The Plan requested a reopen and noted that incorrect information was submitted in the case file and the code under appeal is 51990.  The Plan notes code 51990 was denied as exceeding the MUE limit of 1. This code was billed twice for the same date of service by two providers of the same specialty (urology), under the same group Tax ID. The Plan reviewed these documents and made the determination to uphold the original denial. As to procedure code 55899, this code has been sent to be reprocessed. 

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 documentation shows code 51990 was billed twice by two providers in the same specialty and was not billed with a required modifier to show a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for surgery services provided to the enrollee on April 7, 2022, and billed under code 51990.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that your dentist identified the cause of the 
pain as a cracked tooth and the necessary repair is to install a crown. You say the evidence from the photo and 
x-ray of the tooth clearly show the crack. The Plan denied your request. The Plan says this service is not a 
covered expense under the 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 
buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) Tooth 12, core 
buildup, including any pins when required (D2950) x2, prefabricated post and core in addition to crown 
(D2954) and pontic - porcelain/ceramic (D6245) x2. You asked the Plan to pre-approve dental services. 

You say that that it is important that the requested services 
be approved because the enrollee cannot eat properly. The Plan denied your request. The Plan says this service 
is not covered 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. Core buildup, including any 
pins when required, prefabricated post and core in addition to crown and pontic - porcelain/ceramic are not 
covered under the Plan's dental benefits. This benefit includes non-Medicare covered comprehensive dental 
services - Restorative services: $0 copay. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You previously received covered extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated of Tooth #12 on date of service April 21, 2023. Therefore, the Plan does not have to pre-
approve the crown - porcelain/ceramic (D2740) Tooth #12. 
 
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 
buildup, including any pins when required (D2950) x2, prefabricated post and core in addition to crown 
(D2954) and pontic - porcelain/ceramic (D6245) x2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory infusion pump billed with code E0781-RR 
for date of service February 27, 2023. 
 
You asked the Plan to pay for code E0781-RR. You say that this item was medically necessary. The Plan 
denied your request. The Plan says you did not bill this service with a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules state that when providing rental equipment, providers 
must append one of the following modifiers to indicate its status: KH, KI, or KJ. 
 
In this case, the claim you submitted just shows that you billed E0781-RR. Although you appeal contends that 
you appended modifier KJ, that modifier is not on the actual claim you submitted. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0781-RR have not been met. Therefore, we decided that the Plan does not have to pay for 
the ambulatory infusion pump billed with code E0781-RR for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PCR respiratory panel (87798) provided January 30, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that please review the medical documents to 
support the diagnosis coding and medical necessity of the denied line items. The Plan denied your request. The 
Plan says CPT 87798 is listed as a Group 8 code. Group 8codes are not covered. 
 
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 code 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, CPT code 87798 is a Group 
8 code. Group 8 codes are NOT covered for a given beneficiary on the same DOS when more than 2 codes are 
billed for the same intended use. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the PCR 
respiratory panel (87798) provided January 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (PT) visits (G0151x7). 
 
You asked the Plan to pre-approve home health services. You say that the additional PT visits are medically 
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 reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehab services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The 
requested home health services are not medically necessary. 
 
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 home health physical therapy (PT) visits (G0151x7).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 27, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 27, 2023, forward. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric care from July 27, 
2023, forward. Our reviewer says that the service is not medically necessary. Our physician reviewer found it 
appears that the beneficiary has reached maximum benefit from her inpatient psychiatric stay. The beneficiary 
is noted to be in no psychiatric distress and is eating and sleeping adequately. She is complaint with her 
medications. The progress notes do not indicate that the beneficiary has been aggressive with peers or staff on 
the unit or has had any recent attempt to harm herself during the disputed period. As of the last covered day, 
there is no indication in the available medical records that the beneficiarys psychiatric symptoms could not be 
managed on a less restrictive basis. As of the last covered day the beneficiary did not express any active 
suicidal ideation or intent, or any intent to harm themselves or anyone else. The beneficiary was not exhibiting 
any other significant symptoms. She had no acute psychiatric issues that would require continued inpatient care 
beyond July 27, 2023. The beneficiary has chronic symptoms. The available medical records do not support 
that continued inpatient care will change these symptoms or the beneficiarys current condition. 
 
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 psychiatric care from July 27, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 27, 2023, 
forward.