Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 10, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that the provider does not choose what patients to 
see. 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 November 10, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT), abdomen and pelvis; 
with contrast material(s) (74177). 
 
You asked the Plan to pre-approve a CT scan. You say that the enrollee needs this service. The Plan denied 
your request. The Plan says the requested imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found the provided documentation 
indicates the requested computed tomography (CT) is part of a pheochromocytoma workup. The reviewer 
found that blood and urine testing results as part of this workup to suggest a need for imaging was not 
provided. Also, clinical history of symptoms and objective findings on examination did not suggest 
pheochromocytoma or other condition to warrant CT. Therefore, the reviewer found that the requested CT is 
not medically 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT), abdomen and pelvis; with contrast material(s) (74177).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for code 77300 for date of service December 22, 2021.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and noted that records have now been received for codes 57155, 77295, 77771, 77290, and 77334 and were routed to the appropriate area for processing.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that the National Correct Coding Initiative (NCCI) was developed to prevent inappropriate payment of services that should not be reported together. If a provider reports two codes of an edit pair, only the Column 1 code is payable. Medicare guidance says an NCCI PTP edit exists between codes 77771 and 77300. This PTP edit has a modifier indicator of 0, which indicates modifiers associated with NCCI are allowed, however, in this case, an appropriate NCCI modifier was not billed with this PTP code edit on the claim submitted. Therefore, we decided that the Plan does not have to pay for medical services billed under code 77300 for date of service December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for code 81002 on August 9, 2022.
You asked the Plan to pay these services. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted requested medical records were received for codes 99213, 99214, 80307 and were routed to the appropriate team for processing.
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 81002 is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to bypass the edit. Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for code 81002.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99135 billed for date of service 
April 13, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99135. You say that this should be paid for. The Plan 
denied your request. The Plan says procedure codes 99100 and 99135 are considered bundled and not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99135 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99135 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99135 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99135 billed for date of service 
April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drugs, Monovisc, Orthovisc, Synvisc 
or Synvisc One. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed the preferred drugs, Monovisc, Orthovisc, Synvisc or Synvisc One. 
The reviewer also found that the documentation does not support that Monovisc, Orthovisc, Synvisc or Synvisc 
One would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
Therefore, the reviewer found that the step therapy criteria have not been 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continued coverage for a portable oxygen concentrator for the enrollee.
You asked the Plan to provide continued coverage for this equipment. You say that this equipment is required by the enrollee. The Plan denied your request. The Plan says based on confirmation from the equipment provider, the enrollee received the equipment on April 20, 2020, and was provided coverage for the equipment up to March 20, 2023. The enrollee is not due for a new set of equipment until month 61 in 2025. The Plan noted according to the Medicare guidelines, the equipment provider is responsible for continued care, service, and maintenance of the equipment from months 37-60.
The Plan is correct in this case. Medicare rules state that capped rental items are covered for 36 months. The equipment provider has confirmed the enrollee received 36 months of coverage. Therefore, we decided that the Plan does not have to provide continued coverage for a portable oxygen concentrator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0241U) provided on February 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0241U) provided on 
February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99220) provided on October 22, 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 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit".  
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 99220 is 
not supported by the records provided. Our reviewer found that the records do not indicate the encounter 
required medical decision making of high complexity. 
 
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 (99220) provided on October 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pegfilgrastim injection, excludes biosimilar, 0.5 mg 
(J2506). 
 
You asked the Plan to pre-approve the injection. You say that say the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee has not tried and 
failed the Plan's preferred drugs and Pegfilgrastim is not medically necessary given the enrollees current 
conditions. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 the case file does not contain documentation of trial and failure of two of the preferred drugs, 
Ziextenzo, Udenyca, Fulphila, Nyvepria, Stimufend, and Fylnetra.  The documentation does not support that 
two of the preferred drugs (Ziextenzo, Udenyca, Fulphila, Nyvepria, Stimufend, and Fylnetra) would likely be 
less effective, and/or would likely have adverse effects 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pegfilgrastim injection, excludes biosimilar, 0.5 mg (J2506).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for fresh frozen plasma (P9059) billed for August 27, 2022.

You asked the Plan to pay for this claim. 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 for insufficient information in the case file. The Plan requested a reopen and demonstrated that the claim was submitted for professional services. Per MLN 901346 the medically unlikely edit MUE) value is not determined by place of service, but rather by the type of billing provider. It was also noted multiple attempts were made to obtain medical records however, no records were received for this case and the Plan was unable to determine how many units were administered.

The Plan is correct in this case. 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 this claim have been met. Therefore, we decided that the Plan does not have to pay for fresh frozen plasma (P9059) billed for date of service August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on August 16, 2022.
You asked the Plan to pay for the panoramic radiographic image. You say that you disagree with this 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 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 the requested item or service was exhausted on date of service August 8, 2022.
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on August 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery may be covered if certain 
criteria are 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found there is no documentation of 
fracture bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service October 17, 
2022. 
 
You asked the Plan to pay for procedure code 99253. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the requested block is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested block 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case.  
Our physician reviewer found a genicular nerve block is experimental for knee pain as more research is needed. 
Therefore, the reviewer found that a genicular nerve block 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit; includes a personalized prevention 
plan of service (pps), initial visit (G0438) and an advance care planning visit (99497) provided on October 28, 
2022. 
 
You asked the Plan to pay for an annual wellness visit and an advance care planning visit. You say that you did 
not know that the appointment was scheduled for a wellness visit. The Plan denied your request. The Plan says 
they have paid the maximum amount covered by your plan for this service. The Plan also says that there is a 
$20 copayment for services from an in-network provider for an advanced care planning visit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.  
The records also show that on this same visit, you had an advanced care planning visit which was billed at the 
contracted rate for an in-network provider. You pay a $20 copayment for all in-network visits. Therefore, we 
decided that the Plan does not have to pay for an annual wellness visit; includes a personalized prevention plan 
of service (pps), initial visit (G0438) and an advance care planning visit (99497) provided on October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee is 
participating in a clinical trial and the claim as billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for the services as part of a clinical trial. The Plan does not cover routine 
costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pay for the 
services provided on December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 87634 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87634 is bundled into payment for code 87798. 
 
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 87634 
is a column II code to column I code 87798. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 87634 billed for date of service November 21, 2022.