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

 
We decided that the Plan has to pay for procedure codes 81240, 81241 and 81328 billed for date of service 
January 3, 2023. 
 
You asked the Plan to pay for procedure codes 81240, 81241 and 81328. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says that the provided documentation does 
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 
code 81240 is: F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 
20210G>A variant. The definition of code 81241 is: F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant. The definition of code 81328 is: SLCO1B1 (solute carrier 
organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) 
(eg, *5). 
 
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 procedure codes 81240, 81241 and 81328. Our reviewer says 
that procedure codes 81240, 81241 and 81328 meet criteria for payment. Our reviewer found that the provided 
laboratory reports document a F2 Prothrombin coagulation factor (81240), an F5 coagulation factor (81241) 
and a solute carrier organic transporter family, gene analysis (81328). The documented results are normal. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 81240, 81241 and 81328 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 81240, 81241 and 81328 billed for date of service January 
3, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on February 6, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on February 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) (95955) provided on 
February 2, 2023.   
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was not medically necessary.  
 
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 pay for the electroencephalogram. Our reviewer 
says that the service provided is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this case involves an enrollee diagnosed with lumbar radiculopathy and lumbar spinal 
stenosis. The enrollee had a lumbar interbody fusion surgery with EEG monitoring. Based on the medical 
records provided and review of the current peer-reviewed medical literature, there is no support that the EEG at 
issue in this case meets all Medicare criteria to be considered medically reasonable and necessary for this 
enrollee. The current peer-reviewed medical literature and the provided records do not support that EEG 
monitoring is an applicable neuromonitoring modality for lumbar spine 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the electroencephalogram (EEG) (95955) provided on February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick.  

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 an electronic connection, harness, and 
expandable controller. 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 incomplete paraplegia, has 
gross motor control, and 3 out of 5 strength in their upper extremities. Our reviewer also found that the enrollee 
has adequate upper body strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated stainless-steel crown (D2931) provided on 
December 20, 2022. 
 
You asked the Plan to pay for prefabricated stainless-steel crown. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 pay for 
prefabricated stainless-steel crown (D2931) provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated abutment (D60566) and intraoral - periapical 
first radiographic image (D0220) provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the intraoral - periapical first radiographic image has already been 
exhausted. A prefabricated abutment 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, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image was exhausted on date of service May 
5, 2022. Therefore, we decided that the Plan does not have to pay for prefabricated abutment (D60566) and 
intraoral - periapical first radiographic image (D0220) provided on April 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit (E0730) provided to the enrollee on September 7, 2022.
You asked the Plan to pay for the TENS unit. You say that code E0730 is an accepted procedure code. The Plan denied your request. The Plan says that the documentation did not include proof of delivery or medical records. Maximus overturned the Plan's denial. The Plan requested a reopening and submitted the delivery ticket for review.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid physician order, proof of delivery and relevant medical records which support medical necessity. The record does not contain a valid proof of delivery. The delivery ticket provided does not indicate what was delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the TENS unit (E0730) provided to the enrollee on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility visit provided to the enrollee on October 25, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that the records attached support the services provided. The Plan denied your request. The Plan says that there is no network deficiency for these services. Maximus overturned the Plan's denial. The Plan requested a reopening and included the 2022 Evidence of Coverage.
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 the subsequent nursing facility visit provided to the enrollee on October 25, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the complete upper denture (D5110) and complete lower denture (D5120) provided on December 26, 2022
You asked the Plan to provide additional reimbursement for the dental services. You say that you would like for the dentures to be covered. The Plan denied your request. The Plan says that your annual dental maximum benefit for the year has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional documentation.
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 dental services exhausted on date of service December 26, 2022.
The Plan provided documentation showing they had paid $645 towards your dental benefits prior to this date of service. The Plan paid another $537 towards the upper denture received on December 26, 2022. These records show the Plan has approved and paid up to the Plan benefit limit of $1,000 for the year. Therefore, we decided that the Plan does not have to provide additional reimbursement for the complete upper denture (D5110) and complete lower denture (D5120) provided on December 26, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sit to stand lift for the enrollee.
You asked the Plan to pre-approve a sit to stand lift. You say that this is necessary to allow the enrollee to get out of a chair. The Plan denied your request. The Plan says that this is a non-covered item. Maximus overturned the Plan's denial. The Plan requested a reopening and confirmed the enrollee requested an electronic sit to stand lift.
The Plan must follow Medicare rules. Medicare rules say that patient lifts are covered when needed to transfer from bed when the enrollee would be otherwise bed-confined. We looked at the file and Medicare rules. This lift is not for transfer from bed. Medicare does not include coverage for lifts from a chair to standing. Based on this information, we decided that Medicare rules for coverage of a sit to stand lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a sit to stand lift for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies provided to the enrollee on August 24, 2022.
You asked the Plan to pay for these supplies . You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that in the claim history that the Provider has submitted claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per the Medicare guidelines, providers cannot bill separately for these supplies if the unit is rented It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). Also based on the Medicare guidelines, the usual maximum utilization is 2 TENS leads at a maximum of one unit of A4595 per month and 4 TENS leads at a maximum of two units of A4595 per month. The provider is billing the units in excess of the Medicare allowed amount.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed based on the Medicare rules for supplies provided for rental items and the amount of supplies billed exceeding the allowed units billed. Medicare rules for coverage of these supplies have not been met. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies provided to the enrollee on August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for TENS unit supplies provided to the enrollee on August 10, 2022.
You asked the Plan to pay for the supplies. You say that these items are medically necessary. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The provider is billing the units in excess of the Medicare allowed amount. Therefore, this claim was denied correctly.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the provider is billing for supplies separately for rented equipment, which is not allowed. The provider is also billing in excess of the normal units allowed by the billing guidelines. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for TENS unit supplies provided to the enrollee on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341) for all 4 quadrants
You asked the Plan to pre-approve deep gum and root cleaning for all 4 quadrants. You say that the requested dental services is medically necessary. The Plan denied your request. The Plan says that the x-rays provided do not show a hard substance built up on the root of the enrollee's teeth. Maximus overturned the Plan's denial. The Plan requested a reopening and provided legible x-rays for review.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for deep gum and root cleaning for all 4 quadrants. Our Medical Director states that the improved documentation supports that deep gum and root cleaning in all 4 quadrants is/was not medically reasonable and necessary for the enrollee in this case. Our Medical Director found that your condition does not meet criteria for coverage of deep gum and root cleaning for all 4 quadrants.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of deep gum and root cleaning for all 4 quadrants have not been met. Therefore, we decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341) for all 4 quadrants.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services billed from March 17, 2022, to April 11, 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 billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that there was incorrect information submitted by the Plan. The Plan noted that the provider submitted the Notice of Admission (NOA) on January 5, 2023, for the home health care period which started on March 17, 2022. The Plan notes based on Medicare guidelines the deadline for submission of a home health service Notice of Admission (NOA) is to be within 5 days of the start of care. The Notice of admission (NOA) was submitted January 5, 2023 but the care did not start until March 17,2022 which is not within 5 days.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the NOA submitted, and the start of the home health service are not within 5 days of each other. Medicare rules for coverage of this claim have not been met. Therefore, we decided the Plan does not have to pay for home health services billed to the enrollee from March 17, 2022, to April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for naturopath services provided on August 9, 2022, and November 8, 2022.
You asked the Plan to pay for naturopath services. You say that these services were covered in July by the Plan but were not covered in August or November and should be. The Plan denied your request. The Plan says the Plan contract is clear that naturopath services are not covered. Maximus upheld the Plans denial. You requested an ALJ hearing.
The ALJ judge reviewing your case remanded the case back to Maximus stating all dates in question were not reviewed. Maximus reopened your case and found there was enough documentation in the case file to review the services for August 9, 2022.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The Plan contract states that naturopath services are not covered. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for naturopath services provided on August 9, 2022, and November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fulphila for the enrollee.
You asked the Plan to pre-approve Fulphila. You say that you disagree with the denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Fulphila. Our Medical Director states that the requested use of Fulphila is not FDA-approved for the enrollee's diagnosis, and its use is not supported by one of the major drug compendia, and is not sufficiently supported in this setting by clinical research in a CMS-approved medical journal. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of Fulphila.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have to pre-approve Fulphila for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission was 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 correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued SNF services. Maximus determined that the file does not show that a valid notice of non-coverage was delivered two or more days before. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has pre-approve SNF care. The Plan requested a reopen and provided a valid notice of non-coverage.
The medical records show you have a medical history that includes heart disease, COPD, type 2 diabetes, chronic kidney disease, and hypertension. On February 24, 2023, it was noted that the enrollee had Covid-19. You were started on vitamin C, Mucinex, dexamethasone, and Lagevrio twice daily for 5 days. No required skilled nursing services are identified. No required skilled therapy services are identified. The records do not show you required services on an inpatient basis, in a skilled nursing facility setting. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.