Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two more extractions (D7210). 
 
You asked the Plan to pre-approve the extractions. You say that you need to see an oral surgeon to have three 
teeth extracted. You say one tooth is severely infected, and you are at very high risk due to your heart 
condition. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on July 13, 2023 when the Plan authorized 
one extraction. Therefore, we decided that the Plan does not have to pre-approve two more extractions 
(D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  acupuncture. 

You asked the Plan to provide coverage for  this service. You say that this treatment is medically necessary.  The Plan denied your request. The Plan says you do not meet the required coverage criteria. Maximus overturned the Plans denial stating this could be covered under the wellness benefit. The Plan requested a reopen and stated that Maximus did not apply the correct contract coverage. The Plan noted that the contract states acupuncture is covered for low back pain. You are requesting treatment for rheumatoid arthritis, which is not a covered diagnosis. It was also noted that in a conversation with the Plan, you were told that you had a right to pay for this treatment ahead of time and request payment under the wellness benefit. You stated you preferred not to pre-pay and wanted to appeal under the acupuncture benefit. 

The Plan must follow Medicare rules. Medicare offers limited coverage for acupuncture treatments for chronic low back pain.  You are asking for acupuncture treatment for rheumatoid arthritis. You are choosing not to pre-pay and have reimbursement claims applied to your wellness benefit.  Therefore, we decided that the Plan does not have to provide coverage for  acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the electronic connection (E2311), expandable controller (E2377), and harness (E2313) were not medically reasonable and necessary.

You asked the Plan to provide coverage for a group 3 power wheelchair (PWC) and accessories. You say that the requested power wheelchair and accessories are medically necessary.  The Plan denied the electronic connection (E2311), expandable controller (E2377), and harness (E2313) as not being medically reasonable and necessary. 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 the electronic connection (E2311), expandable controller (E2377), and harness (E2313). The medical records show the enrollee is a 22-year-old man with a medical history that includes multiple sclerosis and Blount's disease with osteotomy of the left lower extremity. The Plan is correct in this case. The clinical documentation in the case file does not support that an electronic connection (E2311), expandable controller (E2377), and harness (E2313) 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 a group 3 power wheelchair (PWC) have not been met. Therefore, we decided that the Plan does not have to provide coverage for the electronic connection (E2311), expandable controller (E2377), and harness (E2313) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, E0656).
 
You asked the Plan to pre-approve a pneumatic compression device . You say that this device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, E0656).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99214) and related services (68761, 83861, 92285) provided on September 27, 2022.

You asked the Plan to pay for an office visit and related services. You say that this was medically necessary. The Plan denied your request. The Plan says that this was not authorized.

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 has not provided a copy of the correct Evidence of Coverage for the enrollee's contract. Without this information, the Plan's authorization rules cannot be verified. Therefore, we decided that the Plan has to pay for an office visit (99214) and related services (68761, 83861, 92285) provided on September 27, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0140) provided on November 14, 2022.  

You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan.  The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plans denial for insufficient information in the case file on when the benefit was exhausted. The Plan requested a reopen and provided the required documentation. The Plan notes you had this service on November 14, 2022, and November 15, 2022. Your provider submitted the claim for November 15, 2022, first and that service was paid. Your provider submitted the claim for November 14, 2022, second, and that service was denied as cod D0140 is only covered once per year. 

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, certain limitations apply. 
The record shows you were provided this service on two consecutive days. However, only one could be covered based on your Plan contract. Therefore, we decided that the Plan does not have to pay for dental services (D0140) provided on November 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services described by procedure code(s) 93010, 99292, and 99053 provided to the enrollee on June 28, 2022.

You asked the Plan to pay for these services. You say that the services were medically necessary. The Plan denied your request. The Plan says that there is a procedure to procedure edit that exists between procedure codes 99292 and 93010. Also, procedure code 99053 has a status indicator of 'B' on the CMS Physician Relative Value File. Maximus overturned the Plan's denial. The Plan requested a reopening and confirmed services 99291 and 92950 were paid by the Plan.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate procedure code.

In this case, we have confirmed that code 93010 is a column II code to column I code 92950. This claim has
not been billed with an appropriate modifier to bypass the edit. Also, we have confirmed that code 99292 is a
column II code to column I code 92950. We also find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately payable. 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 services described by procedure code(s) 93010, 99292, and 99053 provided to the enrollee on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents (D4381 x3). 
 
You asked the Plan to pre-approve localized delivery of antimicrobial agents. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
localized delivery of antimicrobial agents (D4381 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture-flexible base (including retentive/clasping materials, rests, and teeth) (D5225) and a lower partial denture-flexible base (including retentive/clasping materials, rests, and teeth) (D5226).

You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided documentation to show your benefit was exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service September 19, 2018. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture-flexible base (including retentive/clasping materials, rests, and teeth) (D5225) and a lower partial denture-flexible base (including retentive/clasping materials, rests, and teeth) (D5226).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for code J3490 billed to the enrollee for date of service September 16, 2022.

You asked the Plan to pay for code J3490. You say that the drug was a necessary part of the enrollee's treatment. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating the code was valid. The Plan requested a reopen and demonstrated that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 27096 that was billed on the same claim. Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable:
1. Use of local anesthesia;
2. IV start;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion; and
5. Standard tubing, syringes and supplies.

Payment for the above is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service. Per the above Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service

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, payment for code J3490 in this case was included in the payment for the administration and infusion services. Medicare rules for coverage of this service have not been met. Therefore, the Plan is not required to pay for these services as billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a 
lumbar laminectomy and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found that lumbar laminectomy can typically either be day surgery or admitted under 
observation. There is no documentation as to why more than 2 midnights are anticipated for this surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care for the enrollee.

You asked the Plan to pre-approve SNF care. You say that the enrollee has trouble walking and needs assistance. The Plan denied your request. The Plan says that the enrollee has used all the skilled nursing facility days that are covered under their plan for the current benefit period. Maximus overturned the Plan's denial. The Plan requested a reopening and provided new records for review.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. 

The file shows that the enrollee received 100 days of SNF care during the benefit period from February 21, 2022, through March 10, 2022, March 21, 2022, through April 1, 2022, April 20, 2022, through May 9, 2022, June 17, 2022, through July 9, 2022, September 23, 2022, through October 7, 2022, and November 11, 2022, through November 28, 2022. The Plan has covered 100 days of SNF care. The Plan also provided documentation to confirm the enrollee was inpatient at the hospital from July 30, 2022, through August 4, 2022, and August 26, 2022, through September 4, 2022. Therefore, the enrollee did not go 60 days in a row without inpatient hospital or SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870 billed for date of service May 20, 
2022.  
 
You asked the Plan to pay for procedure code 95870. You say that the coding was based on billing guidelines. 
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 95870 is 4. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
provided, correctly coded, and medically necessary. Based on this information, we decided that Medicare rules 
for coverage of procedure code 95870 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 95870 billed for date of service May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months continued coverage for a home ventilator, any 
type, used with non-invasive interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you have had problems with 2 machines that do 
not properly reflect actual machine use duration for nearly 2 years. The Plan denied your request. The Plan says 
under Medicare, the request for 9 months of the noninvasive ventilator (NIV) rental (months 4 - 12 of this 
request) is not medically necessary.  
 
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 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document diagnoses of chronic respiratory failure, obstructive 
sleep apnea and morbid obesity with alveolar hypoventilation and emphysema. The provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with 
AVAPS and a back-up rate. The provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. The records 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 months continued coverage for a home ventilator, any type, used with non-invasive 
interface (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36556, 36620, and 76937 rendered on 
September 29, 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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 36556: 
 
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older  
CPT 36620: 
 
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); 
percutaneous 
 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (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 medical record/operative report 
does not include any documentation of insertion of non-tunneled centrally inserted central venous catheter or 
arterial catheterization/cannulation. Therefore, the records do not support CPT 36556 and CPT 36620. 
Additionally, CPT 76937 is considered an add-on code, and would not be reported with a primary procedure 
codes. The denied codes 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 procedure codes 36556, 36620, and 76937 rendered on September 29, 2022.