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

 
We decided that the Plan does not have to pay for the laboratory services (83789-59 and 80307) provided May 
2, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. The definition of code 80307 is drug test(s), presumptive, any 
number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing 
immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass 
spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-
MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. 
 
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 the services. Our reviewer found for code 83789, the 
documentation submitted was reviewed and does not meet criteria. The laboratory report describes urine drug 
test with specimen validity testing. Providers performing validity testing on urine specimens utilized for drug 
testing shall not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific 
gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this 
testing is not separately billed. Therefore, this procedure would be included in Healthcare Common Procedure 
Coding System (HCPCS) G0480. For code 80307, the documentation submitted was reviewed and does not 
meet criteria. The physician order documents "3178ColSprIntPM_HM Colorado Springs Inter Pain Mgmt", 
however tests included in this panel are not included, and therefore, cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (83789-59 and 80307) provided May 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 skilled nursing visits, 6 physical therapy visits, and 11 
home health aide visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are 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 nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to 
improve the enrollees condition, perform a maintenance program to maintain the enrollees 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 6 skilled nursing visits, 6 physical therapy visits, and 11 home health aide visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional power wheelchair accessories
(E2300, E2311, E2313, and E2377).

You asked the Plan to provide coverage for additional power wheelchair accessories. The Plan denied your
request. The Plan says the Medicare coverage criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted
that the medical records show the E2377 Expandable Controller, E2313 Expandable Controller Harness and
E2311 electronic accessory are requested to control power tilt, recline, and power elevating leg rests through
the joystick. The notes state that these are needed when 3 or more actuators are being used. The electrical
connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377)
and harness (E2313) cannot be covered. The medical records do not show there is not a medical need to control
these power options through the joystick. The enrollee's upper limb strength is described as 4/5, which is more
than adequate to be able to control the power options that use their own switches.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the requested upgraded electronics. Medicare does not cover the E2300 seat lift accessory. The medical
records show based the enrollee's upper extremity strength, the clinical documentation does not support that an
upgraded electronic connection is medically reasonable and necessary. Therefore, we decided that the Plan
does not have to provide coverage for additional power wheelchair accessories (E2300, E2311, E2313, and
E2377).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services (x-rays) provided to the enrollee on July 22,
2022.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and noted this claim denied because it was
reported without a required anatomical modifier. The Plan notes the provider needed to bill the anatomic
specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure) to designate the area or part of
the body on which the procedure is performed. The claim does not reflect the correct anatomical modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code and when necessary, the appropriate modifier.

In this case, the claim was not submitted with the appropriate anatomical modifier. Medicare rules for coverage
of this service have not been met. Therefore, we decided that the Plan does not have to pay for imaging
services (x-rays) provided to the enrollee on July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx (0339U) provided to the enrollee on October
25, 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 the Medicare coverage criteria were not met. Maximus overturned the Plans denial for
medical necessity. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The
Plan notes the technical assessment for SelectMDx was not effective until February 17, 2023.

The Plan also notes on the date of service for this SelectMDx test, only Progensa PCA3 and ConfirmMDx had
met the coverage criteria as stipulated in the LCA.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this testing was not available for coverage on the date it was performed.
Therefore, we decided that the Plan does not have to pay for the SelectMDx (0339U) provided to the enrollee
on October 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided on to the enrollee on January 1, 2023,
and billed with code 74018.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial for insufficient in formation in the case file. The Plan
requested a reopen and stated that this claim denied because this service was billed with an inappropriate
"Place of Service" (POS) code. The Plan states the records show the enrollee was noted as an inpatient status
from December 29, 2022, to January 12, 2023. The appealed claim was billed with POS code 22, for outpatient
hospital. Therefore, this claim denied for an inappropriate POS code.

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 claim was billed with an inappropriate POS code. Medicare rules for
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for
imaging services provided on to the enrollee on January 1, 2023, and billed with code 74018.
Appeal type: ER
Decision: Unfavorable

We decided the Plan does not have to pay for medical services coded as 99285 provided to the enrollee on
September 4, 2022.

You asked the Plan to pay for code 99285. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted there was a
clerical error in the original case file. The Plan noted code 36556 was paid and only code 99285 was denied.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Payment of code 99285 requires a
comprehensive history, a comprehensive examination and medical decision making of high complexity. The
medical records submitted don't support a medical decision making of high complexity. Therefore, the billed
current procedural terminology (CPT) code cannot be verified. The Plan noted multiple attempts were made to
contact the provider for additional information.

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 code
99285 were met. Therefore, we decided that the Plan does not have to pay for medical services coded as 99285
provided to the enrollee on September 4, 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 at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not consider
the concerns by expressed by the hospital therapists in the medical records. The records stated that your ability
to participate in intensive therapy was described as limited by the hospital physical therapist, given
your confusion and memory problems.

It was also documented that you refused to fully participate in therapy while you were in the hospital and if you
did participate cooperation was "fair" even with shorter therapy sessions.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say enrollees must be capable
of participating in an intensive rehabilitation therapy program of at least 3 hours of therapy per day at least 5
days per week (or 15 hours a week). The enrollee must reasonably be expected to actively participate in, and
benefit significantly from, the intensive rehabilitation therapy program. Based on the medical records, these
criteria were not met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for dental implants (D6010 and D6011).

You asked the Plan to provide coverage for dental implants. The Plan denied your request. The Plan says dental
implants are not covered under the dental contract. Maximus overturned the Plans denial because a Plan
contract was not submitted with the case file. The Plan requested are reopen and provided the required Plan
contract.

The Plan is correct in this case. 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, dental implants are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to provide coverage for dental
implants (D6010 and D6011) for teeth numbers 6 and 11.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Select MDX testing provided on October 14, 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 Medicare coverage criteria were not met.

Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria. The Plan notes the technical assessment for SelectMDx was not
effective until February 17, 2023. The Plan also notes on the date of service for this SelectMDx test, only
Progensa PCA3 and ConfirmMDx had met the coverage criteria as stipulated in the LCA.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this testing was not available for coverage on the date if was performed
Therefore, we decided that the Plan does not have to pay for the Select MDX testing provided on October 14,
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on May 8, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the submitted 
medical records include laboratory results that indicate the billed services were performed by a health care 
provider other than the billing health care provider. 
 
The Plan must follow Medicare rules. The rules 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the services were not provided by the billing provider. 
However, the records provided do indicate the name of the billing provider on the lab report. As such, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services 
provided on May 8, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Continuous Positive Airway Pressure (CPAP)
device (E0601) for the enrollee.

You asked the Plan to provide coverage for this device. The Plan denied your request. The Plan says the current
device was approved in 2017 on a commercial health plan. The enrollee is now a member of Medicare and
therefore, the Medicare guidelines for coverage apply. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. Based on the criteria, the
continued use or purchase of a CPAP device may be clinically indicated when the AHI (Apnea Hypopnea
Index) is at least 5. The medical records show the enrollee's AHI at the time of the appeal was 1.1.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for coverage of CPAP machines. When enrollee's transition into Medicare, there may be additional criteria that
must be met for CPAP coverage. Based on the records provided, those criteria required by Medicare were not
met at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for a
Continuous Positive Airway Pressure (CPAP) device (E0601) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
due to the complexity of the enrollee's medical needs and the need for a safe discharge plan. The Plan denied 
your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 6, 
2023, to April 24, 2023. 
 
You asked the Plan to pay for SNF care. You say that you are requesting reconsideration of the denied charges. 
The Plan denied your request. The Plan says the documentation does not support billed code FAED1. 
 
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 the records in this case document a diagnosis of morbid obesity. The enrollee's 
weight is listed as 250.4 pounds as of April 11, 2023; provided records, however, do not document the 
enrollee's height or body mass index to confirm the diagnosis of morbid obesity. Provided records in this case 
do not support billing this stay as special care high. The enrollee was not comatose or quadriplegic; there was 
no diagnosis of chronic obstructive pulmonary disease and shortness of breath when lying flat. There was no 
reported fever with pneumonia, vomiting, weight loss, feeding tube, parenteral/IV feedings, or respiratory 
therapy for all 7 days. Records report a historical diagnosis of sepsis but no active septicemia. Records report 
diabetes on insulin but no insulin order changes on 2 or more days. 
 
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 April 6, 2023, to April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam treatment (PBT) (77014, 77523) for the
enrollee.

You asked the Plan to pre-approve PBT. You say that the enrollee has one of the best indications for proton
therapy over IMRT. The Plan denied your request. The Plan says that the services are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for PBT. Our Medical
Director states that the enrollee has a diagnosis of rectal cancer previously treated with resection of the tumor
and 5 fractions of new adjuvant radiotherapy to a total dose of 25 Gray in 5 fractions. The enrollee has
persistent cancer following the initial therapy. There is no documented evidence that the enrollee has metastatic
disease. A potential short course of palliative radiotherapy has been recommended. The enrollee's physician
recommended pencil beam proton therapy, stating that it offers a high rate of local control with a substantially
mitigated risk of major complication. It is documented that the enrollee's tolerance for a more definitive and
protracted course is somewhat dubious at this time. Medicare rules state that the intent of treatment should be
curative. If proton beam radiotherapy is used for a patient with metastatic disease (which is not the case in this
appeal), evidence should be provided to justify the expectation of a long-term benefit (> 2y), as well as
evidence of a dosimetric advantage for proton beam radiotherapy over other forms of radiation therapy. All
other indications are not considered reasonable and necessary and will be denied. The clinical documentation
does not support that the intent of treatment is curative for this enrollee. Our Medical Director found that the
enrollee's condition does not meet criteria for coverage of PBT.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to
pre-approve proton beam treatment (PBT) (77014, 77523) for the enrollee.