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

 
We decided that the Plan does not have to pay for the wig you received on May 31, 2023. 
 
You asked the Plan to pay for the wig. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig you received 
on May 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 21, 2023, to June 
15, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was originally submitted timely 
but later rejected. 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 April 21, 2023. The NOA was not received by the Plan until October 24, 
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 
from May 21, 2023, to June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 01, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service should be covered. 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 office visit (99214) 
provided on August 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on April 25, 2023. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and should be 
covered. 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 laboratory drug testing 
provided on April 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service September 
18, 2022. 
 You asked the Plan to pay for procedure code 71045. You say that supporting medical records were provided. 
The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 71046. 
 
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 71045 is a column II code to column I code 71046. Code 71045 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 71045 
billed for date of service September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on July 06, 2023. 
 
You asked the Plan to pay for the office visit (99213). You say that the service 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 the office visit (99213) 
provided on July 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental surgery services provided on July 20, 2023. 
 
You asked the Plan to pay for dental surgery services. You say that the procedure 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 dental surgery services 
provided on July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 5, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The billed test in this case is not covered under DEX Diagnostic 
Exchange. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 5, 
2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the myocardial perfusion imaging,
tomographic (SPECT) scan and the regadenoson and aminophyllin injections provided on October 17, 2022.

You asked the Plan to waive the cost-sharing for the myocardial perfusion imaging, tomographic (SPECT) scan
and the regadenoson and aminophyllin injections. You say that you have met your out-of-pocket maximum
prior to this service. The Plan denied your request. The Plan says this cost sharing was charged correctly.
Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated the injections are
Part B Medications that require a coinsurance. The Plan is correct in this case. Your contract with the Plan
clearly says that you must pay a $200 copayment for SPECT scans and a 20% coinsurance for Medicare Part B
prescription drugs.

You have been asked to pay a $200 copayment for the myocardial perfusion imaging, tomographic (SPECT)
scan and a 20% coinsurance for the regadenoson and aminophyllin injections. The myocardial perfusion
imaging, tomographic (SPECT) scan falls within the SPECT scans benefit category and the regadenoson and
aminophyllin injections fall within the Medicare Part B prescription drugs 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 cost-sharing for the myocardial perfusion imaging, tomographic (SPECT) scan and
the regadenoson and aminophyllin injections provided on October 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on April 
12, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was supposed to be 
a screening colonoscopy, not a diagnostic. 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $200 copayment for a diagnostic colonoscopy. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 a diagnostic colonoscopy 
provided on April 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on May 23, 
2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you were being transported 
between facilities and should not have to pay. 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 $245 
copayment for ambulance services. 
 
You have been asked to pay a $245 copayment for an ambulance ride. This item/service falls within the 
ambulance services 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 ambulance ride 
provided on May 23, 2023.
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 this is the safest discharge plan, allowing 
the highest potential for enrollee's recovery, preventing further deterioration and the best use of medical 
management. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and is currently unstable for transfer to an LTACH.  
 
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 was admitted with sepsis, acute on chronic hypercapnic hypoxemic 
respiratory failure, and an abdominal wound.  The enrollee has undergone a tracheostomy and percutaneous endoscopic gastrostomy tube placement. The 
enrollee's abdomen is noted to be distended, semi-firm, tympanic, and with hypoactive bowel sounds in the past 
few days, which is a new change that is attributed to ileus. The enrollee's tube feeds are on hold and is not yet 
stable for transfer. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a fixed bridge (D6740 x 2 and D6245 x 2) for
the enrollee.

You asked the Plan to provide coverage for a fixed bridge (D6740 x 2 and D6245 x 2). The Plan denied your
request. The Plan says the dental records provided do not support the requested services. Maximus overturned
the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The
Plan noted that there are not records submitted to show the enrollee has a documented physical or neurological
disorder that would preclude placement of a removable prosthesis.

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.

The Plan covers a fixed bridge (D6740 x 2 and D6245 x 2) for exceptional cases where there is a documented
physical or neurological disorder that would preclude placement of a removable prosthesis. The records
provided do not show a condition present in the enrollee that prevents the use of a removable prosthesis.
Therefore, we decided that the Plan does not have to provide coverage for a fixed bridge (D6740 x 2 and
D6245 x 2) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic 
connection, pelvic kit, and height/angle adjustable cantilever flip armrests for a power wheelchair. 
 
You asked the Plan to pre-approve expandable controller assembly, pelvic kit, and cantilever flip armrests. You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says the upgraded 
electronics exceed the enrollee's medical needs, and the pelvic kit/armrests are already included in the approved 
wheelchair components. 
 
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 expandable controller assembly, pelvic 
kit, and cantilever flip armrests. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has adequate 
strength to manage the wheelchair's standard power drives. The pelvic kit and adjustable cantilever flip 
armrests are unbundled from the wheelchair and are included with the wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller assembly, pelvic kit, and cantilever flip armrests have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, 
electronic connection, pelvic kit, and height/angle adjustable cantilever flip armrests for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a custom platform and extra-large platform
coded as K0108 for the enrollee.

You asked the Plan to provide coverage for a custom platform and extra-large platform coded as K0108. You
say that at the time of the appeal, these items were medically necessary. The Plan denied your request. The
Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the right criteria. The Plan noted this was a request for footplate
accessories: K0108 custom platform and extra-large platform. The Plan noted that these parts were miscoded
on the request. The Plan notes that K0108 cannot be used items that have a specific code. The appropriate
codes for these items are K0040, K0041 and K0042. K0108 cannot be used for these items and was incorrectly
requested and/or coded.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules providers must use the
appropriate codes for items or services requested.

Based on the information provider, this request was not submitted with the correct codes as is required by the
Medicare rules. Therefore, we decided that the Plan does not have to provide coverage for a custom platform
and extra-large platform coded as K0108 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 8, 2023. 
 
You asked the Plan to pay for the home health services. You say that you have provided medical records to 
show the medical necessity of these services. The Plan denied your request. The Plan says you billed this claim 
with an incorrect Type of Bill code.  The Plan also says that you did not bill one of the required Q codes. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 
 In this case, you billed the services in dispute with Type of Bill code 0323, which is not correct. Final claims 
should be billed with code 0329. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional units of code 97750, defined as physical 
performance test or measurement (for example, musculoskeletal, functional capacity), with written report, each 
fifteen minutes, performed on August 10, 2023. 
 
You asked the Plan to pay for two additional units of code 97750. You say that two additional units of 97750 
should be paid as billed because they are supported in the documentation. The Plan denied your request. The 
Plan says two additional units of 97750 are denied because they are not supported in the record. The record 
does not support the total time required for these services.   

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 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 two additional units of code 97750. Our reviewer says that 
the documentation does not support two additional units of 97750. Our reviewer found that the documentation 
does not support that the total the time reported for these services was spent actually performing the physical 
performance test or measurement. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two additional units of code 97750 have not been met. Therefore, we decided 
that the Plan does not have to pay for two additional units of code 97750, defined as physical performance test 
or measurement (for example, musculoskeletal, functional capacity), with written report, each fifteen minutes, 
performed on August 10, 2023.
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 IRF is the best place for the enrollee to regain 
maximum function. The Plan denied your request. The Plan says the IRF services are not medically necessary.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. 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.