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

We decided that the Plan does not have to provide coverage for a humidifier (E1399) attachment to be used
with an E0466 non-invasive ventilator.

You asked the Plan to provide coverage for a humidifier. The Plan denied your request. The Plan says the
requested humidifier is an item bundled into the ventilator rental reimbursement and not separately covered by
Medicare. The Plan also stated a separate standard written order was not submitted for this humidifier.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that the issue was not medical
necessity but that this item is not separately billable to Medicare and cannot be requested separately for
coverage determination.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules state providers must
request items and services appropriately. In the case the humidifier is being requested separately which is not
covered and/or payable by Medicare.

Therefore, we decided that the Plan does not have to provide coverage for a humidifier (E1399) attachment to
be used with an E0466 non-invasive ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. 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 follows Medicare rules. Medicare rules say that both percutaneous vertebroplasty (PVP) and 
percutaneous vertebral augmentation (PVA) will be considered reasonable and necessary for osteoporotic 
conditions when certain criteria are met. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
evidence of an acute fracture and there is no evidence of spinal instability or fracture instability. There is no 
neurologic deficit documented. Fracture stabilization surgery is not medically needed. Bracing is the best 
treatment for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for MyOwn Skin, includes harvesting and
preparation procedures (Current Procedural Terminology (CPT) code (Q4226) for the enrollee.

You asked the Plan to provide coverage for this procedure. You say that at the time of the appeal, this treatment
was medically necessary. The Plan denied your request. The Plan says this treatment is not covered by
Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that whether or not the
treatment was necessary was not of issue as the procedure is not covered by the Food and Drug Administration
(FDA) or Medicare. The Plan noted that search of the product shows at the time of the appeal it was not
available for sale to providers. The product has been submitted to the FDA for a BLA (Biologics License
Application). FDA rules require that the product be withdrawn from the market during the application process.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover investigational
procedures or products that do not have FDA approval. We have confirmed that MyOwn Skin was/is not
presently available for distribution.

Therefore, we decided that the Plan does not have to provide coverage for MyOwn Skin, includes harvesting
and preparation procedures (Current Procedural Terminology (CPT) code (Q4226) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466) for the enrollee.

You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for
the enrollee. The Plan denied your request. The Plan says that a home ventilator is not medically necessary.
Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply
the correct criteria.

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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as
not reasonable and 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 home ventilator. Our reviewer says
that that a home ventilator is not medically reasonable and necessary for the enrollee in this case. The patient
has documented COPD and obstructive sleep apnea and requires CPAP therapy but did not tolerate use. The
next step would be to attempt BIPAP therapy for comfort and tolerance, not a home ventilator. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator.

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 (E0466) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 20, 
2023. 
 You asked the Plan to pay for procedure code 81345. The Plan denied your request. The Plan says payment for 
code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80048) provided on June 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 find that CPT code 80048 is not supported in the medical record. Specifically, the Clinical Laboratory 
Improvement Amendments (CLIA) number on the claim form (10D2145635) does not match the CLIA number 
documented in the records (25D2258804). Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (80048) provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 23, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for avulsion of nail plate, partial or complete, simple; single 
(11730) provided on June 6, 2023, by an out-of-network (OON) provider.  
   
You asked the Plan to pay for avulsion of nail plate with an out-of-network provider. You say that the service 
was medically necessary. The Plan denied your request. The Plan says this provider is not in-network, and the 
services were not referred by a network provider or rendered in an in-network facility. These services were not 
urgent or emergent, nor were they approved in advance. 
 
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 avulsion of nail plate, partial or complete, simple; 
single (11730) provided on June 6, 2023, by an out-of-network (OON) provider.
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 the enrollee needs IRF services to achieve mobility. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
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: 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement; however, the enrollee does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. The enrollee can receive further services at a lower level of 
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: 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 the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved.  
 
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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility.  There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain the enrollee's functional status.  The enrollee can 
receive further services at a lower level of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 31, 
2023. 
 
You asked the Plan to pay for procedure code 85060. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 85060 has technical component indicator of 8. The claim was billed as an 
outpatient. Based on this information, we decided that Medicare rules for coverage of procedure code 85060 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 85060 billed 
for date of service August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service October 24, 
2022.  
You asked the Plan to pay for procedure code 76942. You say that medical records were provided. 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 76942 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided or medically 
necessary. The unit of service for these codes is the patient encounter, not number of injections Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service October 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service March 18, 
2023, to April 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that a change in ownership is a valid exception for a 
late NOA. The Plan denied your request. The Plan says an NOA is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that a valid NOA was not submitted with an admission date that 
matches the admission date on the claim at issue. 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 
the home health care billed for dates of service March 18, 2023, to April 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87511, 87556, 87640, 87653, 87798) 
provided on July 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says per Local Coverage Article Billing and Coding: MolDX: Molecular 
Syndromic Panels for Infectious Disease Pathogen Identification Testing (A58761), only one unit of service 
can be billed for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87481, 87511, 87556, 87640, 87653, 87798) provided on July 12, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  practitioner services provided on April 5, 2023, billed with 
procedure code 74176-26. 
 
You asked the Plan to pay for  the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says primary explanation of benefits was not received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has to receive an 
explanation of benefits (EOB) from the enrollee's primary insurance carrier before this claim can be 
considered. As the secondary insurer, the Plan cannot be held responsible for the practitioner services provided 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for  practitioner services provided on April 5, 2023, billed with procedure code 74176-26.