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

 
We decided that the Plan does not have to pay for laboratory services provided on December 1, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require or waive prior authorization rules for obtaining POS services. The Plan contract says that outpatient diagnostic 
tests require prior authorization. 
 
We looked at the file and Medicare rules. The laboratory services at issue were not authorized. Based on this 
information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chronic care management visit provided on May 10, 2022. 
 
You asked the Plan to pay for chronic care management visit. You say that you are appealing this denial. The 
Plan denied your request. The Plan says no "initiating visit" was performed within the prior 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of chronic care management visit have 
been met. No supporting medical records were submitted to justify payment of this claim as it has been billed. 
Therefore, we decided that the Plan does not have to pay for a chronic care management visit provided on May 
10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy services provided on February 9, 2023, 
billed with code 31645-51. 
 
You asked the Plan to pay for the services as billed. You say that this was billed correctly and should be paid.  
The Plan denied your request. The Plan says this would be included in payment for code 32663. 
 
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 31645 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial. 
 
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 as billed. Our reviewer says that the documentation does not support separate payment for code 31645. Our reviewer found the documentation does 
not support that a separately reportable therapeutic procedure with aspiration of the tracheobronchial tree was 
performed. The documentation supports a scout procedure that was performed prior to the main procedure 
(thoracoscopy), which is not separately reportable. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the bronchoscopy services provided on February 9, 2023, billed with code 31645-51.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power leg elevation feature (E1012).  
 
You asked the Plan to pre-approve a power leg elevation feature. You say that  the enrollee needs this feature to 
relieve swelling.  The Plan denied your request. The Plan says this feature is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that this feature is covered when it is medically 
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 power leg elevation feature. Our 
reviewer says that this upgrade does not meet criteria for coverage. Our physician reviewer found that a 
Periscope Evaluation states that the enrollee does not need elevating leg rests on the power chair. A Periscope 
Evaluation indicates that the enrollee could use additional of transfer handles to a wheelchair to allow the 
enrollee to have support for safe transfers. The enrollee can stand pivot to a lift chair to elevate legs and 
perform independent weight shifting. There is no evidence of edema or lower extremity conditions that require 
power leg elevation.  
 
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 power leg elevation feature have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power leg elevation feature (E1012).
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. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Willowwood Meta Shock Foot (L5987). 
 
You asked the Plan to pre-approve the Willowwood Meta Shock Foot. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Willowwood Meta Shock Foot. Our 
reviewer says that the enrollee does not need this item. Our physician reviewer found the patient uses a walker 
and wheelchair which is not consistent with K3 level ambulation. 
 
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 Willowwood Meta Shock Foot have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Willowwood Meta Shock Foot (L5987).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 pre-approve the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found that in this case, there is no documentation on physical examination of three or more positive 
test results.  The clinical value and effectiveness of an SIJ injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature. The review has 
determined that the service at issue does not meet LCD criteria and is not medically reasonable or necessary. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99205) provided on December 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter". 
 
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 use of code 99205 is not supported by the records provided. Our reviewer found that the medical records submitted did not support a 
high level of medical decision making or the total time required of the code billed. 
 
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 the services (99205) provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a C-Leg microprocessor knee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical need for this orthosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the physician's medical records do not support that the enrollee requires a K3 microprocessor knee, 
or a K3 foot. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a C-Leg microprocessor knee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate that fusion is the appropriate treatment.  The Plan denied your request. The Plan says this request does 
not meet the standard of care because imaging and symptoms reveal additional significant pathologies that are 
unlikely to benefit from the procedure 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the cause of back pain is unclear. There is no documentation of magnetic 
resonance imaging showing only Modic endplate changes without foraminal stenosis or facet degenerative joint 
disease. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 6, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that the enrollee could not choose an in-network 
provider. The Plan denied your request. The Plan says this was not authorized. 
 
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 nursing facility care provided on January 6, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code(s) 88104, 88305, 88312, and 88361 billed for date of service April 12, 2022.
You asked the Plan to pay for these services. You say that at the time of the appeal, you stated the 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 provided additional information. The Plan noted that the appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the technical component (TC) of the service. If the interpretation is performed in the physician's office and the enrollee received the TC service in the provider-based outpatient hospital setting, the physician assigns POS code 22, for On-Campus-Outpatient Hospital, or POS 19, for Off Campus-Outpatient Hospital, on the claim for the interpretation or PC. A corrected Claim in which the POS code was updated from 24 to 81 to show an independent laboratory was submitted by the provider.
However, at the time of the appeal review, the denial applied correctly as the TC was performed under the POS 22 and services would have required the 26 modifier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate POS code. In this case, the original claim could not be paid as billed due to an error with the POS code reported. The Plan submitted documentation to show a correct claim was submitted. Therefore, we decided that the Plan does not have to pay for procedure code(s) 88104, 88305, 88312, and 88361 as originally billed for date of service April 12, 2022. As noted above, a corrected claim was submitted and reviewed by the Plan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services billed for July 27, 2022 under Claim A.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that Claim A denied because it was bundled as part of the global surgical fee reported on the same day as major surgical procedure 44005 (Enterolysis (freeing of intestinal adhesion) and was billed under Claim B by the same provider.
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, code 99291 could not be paid as billed due to the global billing relationship to codes billed on Claim B. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee on July 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Miera Leadless Pacemaker (33274) provided to the enrollee on February 1, 2022, and billed under claim Claim A with code 33274.
You asked the Plan to pay for this claim . You say that this service and pacemaker should be paid. The Plan denied your request. The Plan says Medicare billing and coverage criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that Claim A denied because leadless pacemakers are not allowed when billed without a required modifier and/or diagnosis code. In addition, according to the Medicare NCD, this device is only covered for enrollee's participating in a Medicare approved clinical study.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare does not cover this device outside of an approved clinical trial. The medical records do not show the enrollee was participating in a clinical trial and the claim was not billed correctly with the required modifier.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for a Miera Leadless Pacemaker (33274) provided to the enrollee on February 1, 2022 and billed under Claim A with code 33274.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on August 19, 2021.
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on August 19, 2021.
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 admission to LTACH is medically 
necessary for enrollee's care and meets the criteria for placement. The Plan denied your request. The Plan says 
the enrollees records do not show you need continued treatments and care that can only be given in a hospital 
setting. When are ready to leave the hospital, services needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services billed to the enrollee under Claim A and code 99223 for June 7, 2022.
You asked the Plan to pay for these services. 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 Claim A denied because payment for this service was included in the billing and payment of Claim B and code 93286. The correct billing of this service needed to include modifier 59, which is used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury.
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 due to the omission of a required modifier. Medicare rules for coverage of these services.
The Plan notes this service was included in the payment of claim 820221880078820 (Claim B). have not been
met. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee under
claim 820221880078757 and code 99223 for June 7, 2022.