Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary and the 
patient will be compliant with this device. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary. The patient's needs can be met with a bilevel positive airway pressure (BiPAP) device 
with average volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the provided records in this 
case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
However, the provided records document that the home ventilator is being requested for use in intelligent 
volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP 
device with average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. The provided records in this 
case do not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as 
opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on January 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for x-ray services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for x-ray services provided on January 13, 2023, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiology (C8929) and drug requiring detailed coding (Q9957) provided to the enrollee on August 8, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the echocardiology and drug requiring detailed coding. You say that you would like this claim to be reprocessed for payment. The Plan denied your request.
The Plan says that there is no documentation this enrollee was referred to this non-contracted provider by a contracted provider, as well as no indication any attempt was made to obtain prior authorization for the out-of-network services. Maximus overturned the Plan's denial. The Plan requested a reopening and provided the applicable Evidence of Coverage.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the echocardiology (C8929) and drug requiring detailed coding (Q9957) provided to the enrollee on August 8, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the test panel is a single test with multiple components 
and is characterized by a single unit of service (UOS =1). 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed as a single unit of 
service. 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 the laboratory services rendered on 
November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay full cost for insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular (Current Procedural Terminology (CPT) code 33208) provided to the enrollee on January 14, 2022.
You asked the Plan to pay full cost for this claim. The Plan denied your request. The Plan says per the manufacturer, these leads are covered under a lifetime warranty. The Plan states they did not see any indication in the records provided for the Plan's review that available credit was requested from the manufacturer. The Plan states even if the provider chooses to use a new vendor, they still must report the credit (whether it was received or not) from the original vendor. Maximus overturned the Plans denial because the case file did not contain the warranty information cited by the Plan. The Plan requested a reopen and provided the required warranty information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific guidelines for payment of claims for replacement or recall of equipment under warranty. Per review of the warranty, Medicare is not responsible for the full cost of the replaced device if the hospital is receiving a partial or full credit, either due to a recall or service during the warranty period.
Therefore, we decided that the Plan does not have to pay full cost for insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular (Current Procedural Terminology (CPT) code 33208) provided to the enrollee on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. You may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured 
pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used 
at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the records show that the enrollee has radiculopathy leg pain symptoms, which are a 
contraindication to the Intracept procedure. The cause of the enrollee's back pain is also unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power arm brace (MyoPro) (L8702).  
 
You asked the Plan to pre-approve a power arm brace . You say that  this device is the enrollee's best 
opportunity for regaining meaningful use of their left upper limb. The Plan denied your request. The Plan says 
experimental and investigational procedures are not covered. 
 
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 power arm brace. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollees condition or in widespread use for this enrollees condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 power arm brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power arm brace (MyoPro) (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 24, 2023. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
without the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided 
on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 7, 
2022. 
 You asked the Plan to pay for procedure code 87481. The Plan denied your request. The Plan says payment for 
code 87481 is bundled into payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. 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 87481 billed for date of service December 7, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you went to hospital rush for high blood pressure, in 
hospital for 5 days to fix bleeding in stomach and want inpatient rehabilitation. The Plan denied your request. 
The Plan says your records do not show that you have complex rehabilitation needs that require frequent 
evaluation by a rehabilitation doctor. Services needed may be provided safely in a lower level of care. 
 
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.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller (E2377) with harness (E2313) and electronic connection (2311) for a power wheelchair.
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 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller (E2377) with harness (E2313) and electronic connection (E2311). The enrollee was a then 65-year-old woman with a history of multiple strokes with residual left sided hemiplegia/hemiparesis, diabetes, peripheral angiopathy, severe obesity, and sacral pressure wounds. The Multidisciplinary Evaluation Report dated August 21, 2022, documents 2-/5 left upper extremity strength, and 3+/5 right upper extremity strength. The Plan is correct in this case. The clinical documentation is insufficient to support that the enrollee in this case required and met the criteria for an expandable controller (E2377) with harness (E2313) and electronic connection (E2311). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these accessories have not been met. Therefore, we decided that the Plan does not have to provide coverage for an expandable controller (E2377) with harness (E2313) and electronic connection (2311) for a power wheelchair.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from September 29, 2022, to 
October 15, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the claim was billed with an invalid 
or missing Federal Information Processing Standards (FIPS) 85 Value Code with amount. 
 
The Plan must follow Medicare rules. Medicare rules say that value code 85 is defined "County Where Service 
is Rendered." This code is required for home health claims to appropriately calculate county-based rural add-on 
payment amounts. The rules also say that Medicare health plans must make reasonable and diligent efforts to 
gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
In this case, you billed FIPS codes of 85 and 61. We agree that these are valid codes. Each of these codes were 
billed with value amounts; however, the Plan failed to provide an explanation for why the value amounts are 
invalid. Therefore, we decided that the Plan has to pay for the home health services provided from September 
29, 2022, to October 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D laboratory/pathology services (88361, 88312, 
88305 and 88112) provided on September 16, 2022. 
 
You asked the Plan to pay for WATS 3D laboratory/pathology services. You say that these services are the 
standard of care and should be paid. The Plan denied your request. The Plan says these services are considered 
experimental and are not covered. 
 
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 WATS 3D laboratory/pathology services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no clinical rationale was provided for the WATS 3D test. The review 
cannot verify that the items/services at issue in this case were medically reasonable or 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 WATS 3D laboratory/pathology services have not been met. Therefore, we 
decided that the Plan does not have to pay for WATS 3D laboratory/pathology services (88361, 88312, 88305 
and 88112) provided on September 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Mounjaro.  
 
Benefits for Mounjaro may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 29, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is no 
documentation how this testing will directly impact the treatment plan. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage (93225, 93226) provided to the enrollee on April 6, 2022.
You asked the Plan to pay for this testing . You say that this claim should be paid. The Plan denied your request. The Plan says this type of testing is not covered for screening purposes by Medicare. 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. Based on the Medicare billing guidelines, this type of testing is not covered solely for screening purposes. There must be medical record documentation of a condition requiring this testing for the purpose of treatment.
Therefore, we decided that the Plan does not have to pay for external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage (93225, 93226) provided to the enrollee on April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37248, 37249, 75825, and 75820 billed for 
date of service July 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records show medical necessity. The Plan 
denied your request. The Plan says the codes are not payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that CPT codes 75820 and 75825 are inclusive to main procedure 
37187. The records do not show that CPT codes 75820 and 75825, billed with the -XU modifier, were not 
unusual non-overlapping services.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 37248 and 37249. Our reviewer found that 
the record states that mechanical thrombectomy was performed at the sites in question and this code was 
previously approved. CPT coding rules state that a separate balloon angioplasty can be reported when it is used 
to treat significant stenosis. No stenosis is mentioned in the operative report. The balloon angioplasties are not 
separately reported and are part of the mechanical thrombectomy.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 37248, 37249, 75825, and 75820 billed for date of service July 29, 2022.