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

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis.  
 
You asked the Plan to pre-approve a CT scan. You say that  you are appealing this denial. The Plan denied your 
request. The Plan says the requested CT is not medically necessary.  
 
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 a CT scan. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that results from the following studies are 
required: colonoscopy is nondiagnostic or suggestive of irritable bowel disease, fecal calprotectin or lactoferrin 
is performed, testing for giardia and celiac disease have been performed. Results of the required studies were 
not provided to meet medical necessity criteria. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the abdomen and pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal objective physical exam findings of 
radiculopathy. The April 14, 2023 physical exam reveals a negative straight leg raise. There is no objective 
evidence of reflex changes, strength or sensory deficits on exam in the proposed area of injection.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 17, 2022, to July 
16, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were provided and billed 
according to Medicare guidelines. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 18, 2022. The NOA was not received by the Plan until July 18, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
June 17, 2022, to July 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would face obstacles 
with an in-network provider. The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0651, E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 11, 2022, 
to December 16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as Sepsis, 
unspecified organism, and secondary diagnosis code R65.20, described as Severe sepsis without septic shock. 
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 hospital services at the DRG 
originally billed. Our reviewer says that documentation does not support the billed codes. Our physician 
reviewer found that the enrollee is a 67-year-old male who was treated in the hospital. He presented with 
shortness of breath and altered mental status. Workup in the emergency department revealed signs of 
pneumonia and Chronic obstructive pulmonary disease exacerbation. He was given low dose oxygen, 
antibiotics, and fluids. He was alert and oriented x3, had normal blood pressure except for 2 times when it 
dipped below Mean arterial pressure 70, but he did not require vasopressors. Bilirubin, platelets, and creatinine 
were all normal without oliguria. Sequential organ failure assessment (SOFA) of 1 might be considered due to 
the brief hypotension, however, there was not at least a 2+ rise in SOFA scores to meet Sepsis 3 criteria for this 
admission. There was insufficient evidence of a life-threatening dysregulated response to infection. Therefore, 
the two codes, A41.9, and R65.20 were not supported for this admission based on the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 11, 2022, to December 16, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
June 23, 2022, to July 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is no covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from June 23, 2022, to July 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoperative electroencephalogram provided on 
November 7, 2022. 
 
You asked the Plan to pay for an intraoperative electroencephalogram. You say that these services are 
medically necessary. The Plan denied your request. The Plan says  this procedure is considered to be 
experimental/investigational. 
 
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 pay for an intraoperative electroencephalogram. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found intraoperative electroenchelopgram is experimental in spinal surgery and 
cervical spine 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 an intraoperative electroencephalogram have not been met. Therefore, we 
decided that the Plan does not have to pay for an intraoperative electroencephalogram provided on November 
7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, 15-21 drug classes (G0482) provided 
October 7, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that kindly review and reprocess the claim 
towards payment. The Plan denied your request. The Plan says under Medicare rules, the number of definitive 
urine drug classes requested are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. 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 chronic pain and was prescribed and reported to be taking 
hydrocodone. A definitive drug testing, 15-21 drug classes (G0482) was performed and is being requested. 
However, the provided documentation did not reveal an unexpected result from a point-of-care urine drug 
screening which is generally all that is needed in this clinical situation. There was no indication that the 
enrollee was using illicit drugs or was abusing multiple other drug classes. Therefore, the definitive drug 
testing, 15-21 drug classes (G0482) will be considered 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing, 15-21 drug classes (G0482) provided October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses billed for date of service January 16, 2023. You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the DME is not supported by the exam. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record provided appears to be a phone conversation with the enrollee presenting problems. 
The records do not include previous physical exams, testing, or imaging to confirm a diagnosis or condition. 
There are no medical records that show a trial of conservative measures. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the orthoses billed for date of service January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft, collection, and application of autologous, 
and therapeutic parenteral drug (D3428, D7921, D9610). 
 
You asked the Plan to pre-approve 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 pre-approve a 
bone graft, collection, and application of autologous, and therapeutic parenteral drug (D3428, D7921, D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a power seat elevation system (E2300), expandable controller (E2377), electronic connection (E2311), harness (E2313), and bag hooks (K0108).
You asked the Plan to provide coverage for a power seat elevation system (E2300), expandable controller (E2377), electronic connection (E2311), harness (E2313), and bag hooks (K0108). You say that this equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria are not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Medicare does not cover power seat elevation systems or bag hooks under any circumstance. The medical records provided show the expandable controller (E2377), electronic connection (E2311), and harness (E2313) exceed the enrollee's medical needs for use of this equipment in the home. Therefore, we decided that the Plan does not have to provide coverage for a power seat elevation system (E2300), expandable controller (E2377), electronic connection (E2311), harness (E2313), and bag hooks (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a protective surface cover and stance fluid extension knee component for a transfemoral prosthesis for the enrollee.
You asked the Plan to provide coverage for a protective surface cover and stance fluid extension knee component . You say that this equipment is medically necessary for the enrollee. 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 coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Medicare requires and enrollee to be a K3 ambulator for coverage of the requested items to be approved. The records provided do not show the enrollee was a K3 ambulator at the time of the appeal. Whether or not the enrollee had to the "potential" to be in the future is irrelevant as the ambulation criteria must be met at the time of approval. Therefore, we decided that the Plan does not have to provide coverage for a protective surface cover and stance fluid extension knee component for a transfemoral prosthesis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223, 99233) provided from September 15, 
2022, to September 20, 2022. 
 
You asked the Plan to pay for hospital care. You say that this is supported in the records. The Plan denied your 
request. The Plan says no documentation of these services has been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hospital care have been met. No 
medical records have been submitted for the billed dates of service. Therefore, we decided that the Plan does 
not have to pay for hospital care (99223, 99233) provided from September 15, 2022, to September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant (D6010), a prefabricated abutment (D6056), and three (3) abutment supported crowns (D6059) for the enrollee.
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says your benefit for the endosteal implant and prefabricated abutment has already been exhausted and the abutment supported crowns are not a covered benefit.
Maximus overturned the Plan's denial. The Plan requested a reopening and stated that these services were not denied based on medical necessity but Plan limits.
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, certain limitations apply. The record shows your benefit for the endosteal implant and prefabricated abutment was exhausted on date of service February 13, 2023, as the Plan approved two (2) of each of these services on that date. Though the Plan offers a dental benefit in excess of Medicare coverage, the abutment supported crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant (D6010), a prefabricated abutment (D6056), and three (3) abutment supported crowns (D6059) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral breast capsulectomy. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that her request for the procedure is to 
alleviate neck pain, shoulder pain, back pain and migraines and is not for vanity. The Plan denied your request. 
The Plan says this is a cosmetic procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable. 
 
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 an outpatient surgery. Our reviewer 
says that the requested surgery is not considered medically necessary. Our reviewer found the record provided 
does not document the presence of intertrigo refractory to treatment or functional impairment of a malformed 
body member. The record does not indicate that the implants were placed for reconstructive purposes in the setting of cancer therapy. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bilateral breast capsulectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided 
January 3, 2023. 
 
You asked the Plan to pay for the orthosis. You say that it is not the responsibility of the DME to ensure that 
the referring physician submits a claim for their services. The Plan denied your request. The Plan says the 
services are not documented in the enrollee's medical records. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have 
not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand 
orthosis (L3960) provided January 3, 2023.