Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 29, 2022 to 
October 14, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. 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 September 29, 2022. The NOA was not received by the Plan until January 
26, 2023. 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 
on September 29, 2022 to October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 02, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided on 
February 27, 2023. 
 
You asked the Plan to pay for the infusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication under section 1862(a)(1)(A) of the Social Security Act.  
 
We looked at the file and Medicare rules. This procedure is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided 
on February 27, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on April 13, 2022.
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus upheld the Plans denial. After the original decision was made it was determined the denial reason was not appropriate and the case was reopened.
Our Medical Director looked at the case file. The enrollee was a then 71-year-old woman with listed diagnoses of Muscle weakness (generalized), Right temporomandibular joint disorder, unspecified, and Radiculopathy, occipito-atlanto-axial region. The enrollee was referred to PT by a dentist. The initial PT evaluation took place on April 13, 2022, at which time the enrollee reported right TMJ pain that had gradually worsened over the previous few months. The treatment plan included soft tissue mobilization and stretching, dry needling, a progressive program of therapeutic exercise, a progressive program of neuromuscular re-education, and therapeutic modalities. One of the PT goals was, "The patient will be independent in a home exercise program in order to maintain gains made in therapy and prevent future problems." The plan was for a frequency and duration of "Initially 1 - 2 times weekly, decreasing in frequency as indicated by patient progression, for 15 sessions." The case file also contains a Daily PT Note dated April 13, 2022. At that time, manual therapy and therapeutic exercise were performed. The source of the enrollee's TMJ symptoms is not clear from the PT documentation. Consequently, it cannot be determined that the symptoms are primarily medical in nature. Patients with TMJ disorder, particularly those with a prominent musculoskeletal component, or cervical or shoulder symptoms, are often referred for PT evaluation and treatment. However, there is a lack of high-quality data demonstrating the overall efficacy of physical therapy in the treatment of the disorder. The clinical documentation does not support that the therapy services provided were medically reasonable and necessary for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic eye visit provided 
on May 12, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic eye visit. You say that you should not 
have a copayment for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $48 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $48 copayment for an in-network diagnostic eye visit. This item/service falls 
within the physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network diagnostic eye visit provided on May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no change in clinical status or new signs/symptoms. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical necessity of a repeat TTE, in the absence of any apparent significant change 
in the enrollee's clinical condition. The documentation at this time would not point to a change in status that 
would support the medical necessity of a repeat TTE. The clinical guidelines do not support repeating a TTE 
with no intervening change in clinical status or new signs, symptoms or physical findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this this enrollee's clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says services must meet criteria in order to be a covered benefit by Medicare and the plan. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the enrollee does not have lymphedema of the chest, trunk, or 
abdomen. The enrollee does not have unique characteristics that would indicate the segmented pump over a 
standard pump. There is no documentation of a trial and failure of the standard pump. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided February 9, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you appreciate prompt review of this 
information and authorization of coverage for the Cxbladder Detect test for this enrollee. The Plan denied your 
request. The Plan says the Cxbladder test remains unproven at this time. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at 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 the Cxbladder Detect test (0012M) provided February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64492 rendered on October 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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 64492 is "Injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary 
procedure)." 
 
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 says that the services at issue in this case were not supported by the medical records. Our reviewer found that the records do not support the 
billed service in this case (CPT 64492-Injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), Cervical or 
Thoracic; third and any additional level(s) ). 
 
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 procedure code 64492 rendered on October 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on March 20, 2023, billed with 
procedure codes 70491 and Q9967. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the reported diagnosis does not support medical 
necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic evaluation of the head and neck 
(head/neck scans) performed by computerized tomography (CT) scanners is covered when the documentation 
supports that the scan is reasonable and necessary. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was not billed with a diagnosis from 
the list diagnoses that support medical necessity for this service. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on March 20, 2023, billed with procedure codes 70491 and Q9967.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 10, 2022, 
through December 12, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) following a fall at home. She was found 
sitting on the couch, bleeding from the head and had agonal breathing requiring intubation upon arrival to the 
ED. The computed tomography (CT) scan showed a subdural hematoma, evidence of ventricular entrapment, 
and a right frontal subarachnoid hemorrhage. She was found to have a blood pressure of 180s/100s, and was 
noted to have seizure activity requiring Ativan and Keppra. Neurosurgery evaluated the enrollee and no 
surgical intervention was offered due to the catastrophic nature of the injuries. The enrollee then extubated and 
later passed away two days after admission. At the time of admission, the enrollee was in such an acute level of 
care without a clear prognosis yet at that point and it was expected to complete a workup and specialist 
consultation as well as stabilization that the hospital care would have likely crossed two midnights.  
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from December 10, 2022, through December 12, 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 procedure code 87641 billed for date of service February 14, 
2023.  
 
You asked the Plan to pay for procedure code 87641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87641 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87641 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87641 billed for date of service February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit provided on April 11, 2023. 
 
You asked the Plan to reimburse you for the physician service. You say that you paid for this service at the 
time of your visit. You say that you have previously been reimbursed in full for visits to this group. You also 
say that this claim should be reimbursed in full. The Plan denied your request. The Plan says payment cannot 
be made for services performed by a provider that has opted out of Medicare.  
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Additionally, there were no medical records submitted to support that 
this service should be covered. Therefore, we decided that the Plan does not have to reimburse you for the 
office visit provided on April 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 11, 2023, to January 14, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that this should be included 
in the surgery. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on January 11, 2023, to January 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foundation pain index (FPI) testing provided on December 
14, 2022. 
 
You asked the Plan to pay for foundation pain index (FPI) testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for foundation pain index 
(FPI) testing provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 17, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
facility care provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab services on September 13, 2023.  
 
You asked the Plan to waive the coinsurance for lab services. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for molecular or predisposition genetic testing. Covered services include but are 
not limited to laboratory tests (outpatient). The provider billed in the amount of $1,300 and the allowed amount 
is $747.84. The plan paid $595.84 for the service. $747.84 - $595.84 = $152. Therefore, results in the total cost 
sharing amount of $152. 
 
 The enrollee has been asked to pay a 20% coinsurance for lab services. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for lab services on September 13, 2023.