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

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that you would like the Plan to reconsider their 
denial of 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 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs. 
 
You asked the Plan to pay for the medication. You say that you did not ask for these drugs. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs.   
Benefits for the medication. may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is currently receiving the proper 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH 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 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: 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare 
guidelines for services in an IRF.  
 
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 that the enrollee is medically stable with no acuity and does not need a pain 
management and rehabilitation physicians supervision 3 times a week in an IRF. No acute rehabilitation 
skilled nursing needs are identified or documented. At the current functional level, the enrollee needs routine 
physical therapy and occupational therapy, but the enrollee does not need specialized intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. The documentation does not support the necessity for admission to an IRF. There is no medical 
complexity, and no rehabilitation nursing needs as described above, the enrollee does not require an IRF stay. 
The enrollees rehabilitation needs can be provided in an alternate and low intensity setting.  
 
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: ER
Decision: Unfavorable

We decided the Plan does not have to pay for code 99284 billed for November 23, 2022.

You asked the Plan to pay this claim. 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 stated that Maximus did not apply the correct billing criteria. The Plan noted
that according to the Medicare Claims Processing Manual Chapter 12, Section 30.6.5, provides definitions
for physicians in Group Practice for Evaluation and Management Service Codes (Codes 99201-99499).
"Physicians in the same group practice who are in the same specialty must bill and be paid as though
they were a single physician. Modifier 25 may be appended to E&M services reported with minor surgical
procedures (with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules (with a
global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intraprocedure,
and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M
service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate
E&M service for the work associated with the decision to perform a minor surgical procedure regardless
of whether the patient is a new or established patient. Per the above Medicare guidelines, the Plan has correctly
denied the claim for payment as the claim was not billed with a 25 modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code and when necessary, the appropriate modifier. In this
case, this claim could not be paid as billed due to the omission of the required 25 modifier. Medicare rules for
coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 99284 billed for date of service November 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the foot x-ray provided on June 21, 2023. 
 
You asked the Plan to waive the cost sharing for the foot x-ray. You say that you were misled and thought you 
had already met your deductible. 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. Your 
contract with the Plan says that there is an $800 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also says that you must pay 10% coinsurance for diagnostic 
tests. 
 
You have been asked to pay $8.19, which is 10% coinsurance of the allowed amount for the foot x-ray ($81.91 
allowed amount x 10% coinsurance = $8.19). This item/service falls within the diagnostic tests benefit 
category. You have also been asked to pay $73.72 towards the deductible. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is an $800 deductible which applies to diagnostic tests. This 
cost sharing is a contractual obligation that had not been met at the time the foot x-ray was received on June 21, 
2023.  
 
You have been asked to pay a total of $81.91 ($8.19 coinsurance + $73.72 deductible = $81.91). 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 foot x-ray provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy-duty power operated vehicle (K0801). 
 
You asked the Plan to pre-approve a group 1 heavy-duty power operated vehicle. You say that your stability 
and ability to walk safely is in danger without the scooter. The Plan denied your request. The Plan says under 
the Medicare guidelines, the request for a scooter (K0801) is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 group 1 heavy-duty power operated 
vehicle. Our reviewer says that a group 1 heavy-duty power mobility device is not medically necessary. Our 
physician reviewer found there is a lack of clinical documentation indicating your level of mobility and 
physical examination findings, specifically with regards to motor strength in the upper and lower extremities. 
There is no indication that you cannot use a cane or walker for assistance with mobility or propel a manual 
wheelchair if you are at risk for falling. Our reviewer also found that there is a lack of information as to 
whether you can safely operate the requested group 1 heavy-duty power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 1 heavy-duty power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 heavy-duty power operated vehicle (K0801).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 4, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 the lab services provided on May 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile imaging services provided on April 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that every code was distinctly different. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. The claim was billed with 11, an office setting place of service code. The 
records do not support that the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the mobile imaging services provided on April 12, 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 enrollee meets all the criteria for IRF services. 
The Plan denied your request. The Plan says the records show there is no need for an intensive rehabilitation 
program.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but the services required can be provided at a 
lower 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.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve autologous bone marrow harvesting for transplantation. 
 
You asked the Plan to pre-approve bone marrow harvesting. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that that the service is considered investigational and experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 bone marrow harvesting. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee will be undergoing a triple arthrodesis. It is crucial that the 
arthrodesis sites fuse properly and fully. Autologous bone graft harvesting has been implemented for many 
years and facilitates and improves arthrodesis. Given the significance and severity of a triple arthrodesis, the 
use of autologous bone graft harvesting is medically reasonable and 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 bone marrow harvesting have been met. Therefore, we decided that the Plan has 
to pre-approve autologous bone marrow harvesting for transplantation.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 84439 and 83735 
for March 16, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 84439 and 83735 for March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for special supplemental benefits for the
chronically ill (SSBCI).

You asked the Plan to provide coverage for these services. The Plan denied your request. The Plan says the
records provided do not confirm you meet the required criteria. Maximus overturned the Plans denial for a lack
of information in the case file. The Plan requested a reopen and provided the required information.

The Plan is correct in this case. The Plan contract states specific documentation is required to show you meet
the criteria for SSBCI benefits. Based on the medical records from your physician, you do not meet these
criteria. Therefore, we decided that the Plan does not have to provide coverage for special supplemental
benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified removable prosthodontic procedure 
(D5899). 
 
You asked the Plan to pre-approve an unspecified removable prosthodontic procedure (D5899). You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says this is not a covered 
service of the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified removable prosthodontic procedure (D5899).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36558 and 77001 provided on September 5, 2022. 
 
You asked the Plan to pay for procedure codes 36558 and 77001. You say that the medical records support the 
billing of codes 36558 and 77001. The Plan denied your request. The Plan says that the medical records do not 
support the billing of codes 36558 and 77001. 
 
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 36558 is Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or 
pump; age 5 years or older. 
 
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 36558 and 77001. Our reviewer says that 
the medical records support the billing of codes 36558 and 77001. Our reviewer found the records clearly 
describe the procedure in appropriate detail and clearly state the position of the catheter at the end of the 
procedure in the right atrium. The records are clearly appropriate for this charge.  
 
Additionally, we have confirmed that code 77001 is an add-on code and as the primary procedure code, 36558, 
is covered, code 77001 is also covered. 
 
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 36558 and 77001 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 36558 and 77001 provided on September 5, 2022.   

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for root tip extraction and surgical extractions.

You asked the Plan to provide coverage for root tip extraction and surgical extractions. The Plan denied your
request. The Plan says the requested services were not available for coverage at the time of the appeal.
Maximus partially overturned the Plans denial for a lack of dental x-rays in the file. The Plan requested a
reopen and provided the required x-rays.

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 records show your benefits for both of these services had
been exhausted at the time of the appeal.
Therefore, we decided that the Plan does not have to provide coverage for root tip extraction and surgical
extractions.