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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controllers (E2377 x2). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controllers. You say that Medicare has reviewed, approved and found this equipment medically necessary. 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, expandable 
controller harness, and expandable controllers. 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 
spinal muscular atrophy. The enrollee has 3 to 4 out of 5 strength in their upper extremities except at the 
elbows. Our reviewer also found that these items are not medically necessary as the enrollee has adequate 
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, expandable controller harness, and expandable 
controllers have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controllers (E2377 x2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on March 30, 2023,
billed with code 93312.

You asked the Plan to pay for code 93312. The Plan denied your request. The Plan says the billing criteria were
not met. Maximus partially overturned the Plans denial for insufficient information in the case file. The Plan
requested a reopen and provided information noting codes 01926 and 36620 were paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code. In this case, we have confirmed that code 93312 is a
column II code to column I code 01926. This claim has not been billed with an appropriate modifier to bypass
the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that
the Plan does not have to pay for the services described by procedure code(s) 93312.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 20, 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 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve the injection. You say that you have multiple sclerosis and several problems 
with your spine. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 you have documentation of radiculopathy. The review has determined that you do not meet 
the LCD coverage criteria. 
 
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 facet joint injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says Euflexxa is not medically necessary as conservative therapy has not 
been adequately trialed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Euflexxa. Our reviewer says that 
treatment with Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found 
that the provider has indicated that the enrollee has not tried and failed conservative therapy for at least 3 
months. The documentation does not support that Euflexxa is medically reasonable and necessary, or safe and 
effective, for the enrollee.  
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 treatment with Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient surgery provided on August 
28, 2023, to August 29, 2023. 
 
You asked the Plan to reduce the copayment for outpatient surgery. You say that you would like the claim to be 
reprocessed because you should have a $250 copayment. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for in-network diagnostic procedures and tests - outpatient hospital and a $250 copayment for in-
network surgery services  outpatient hospital. 
 
You have been asked to pay a total of $3,707.45 for the outpatient surgery. This item/service falls within the 
Outpatient hospital service benefit category. You were billed a $250 copayment and you were charged up to 
20% coinsurance for the services you received. 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 reduce the copayment for the 
outpatient surgery provided on August 28, 2023, to August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes G0483 and 80307) 
rendered on May 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided documentation does 
not clearly show the results of the testing that was done to validate the denied codes. There also was no support 
for the enrollee requiring definitive testing for 22 or more drug classes. 
 
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 laboratory services (procedure codes G0483 and 80307) rendered on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for dates of service June 17, 2023, to June 
18, 2023. 
 
You asked the Plan to pay for code 99222. You say that the diagnosis codes billed are valid. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that F32A has an Excludes1 note in relation to F31.30. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for code 99222 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99222 billed for dates of service June 17, 2023, to June 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided to the enrollee from November 1,
2021, to November 5, 2021, billed at the diagnosis related group (DRG) code 252.

You asked the Plan to pay for this claim. The Plan denied your request. The Plan says the records provided do
not support the billing of DRG 252. Maximus overturned the Plans denial for a lack of medical records in the
file. The Plan requested a reopen and provided additional information.

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. The limited medical records provided do not
support the DRG billed. Medicare rules for coverage of this claim have been met.

Therefore, we decided that the Plan does not have to pay for inpatient services provided to the enrollee from
November 1, 2021, to November 5, 2021, billed at the diagnosis related group (DRG) code 252.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on June 30, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a hospital outpatient 
clinic visit provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (83789) provided August 10, 2023.  

You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as 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 83789 is mass spectrometry and tandem mass 
spectrometry (for example, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere 
specified, qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. CPT code 83789-59 (1 Unit) remains not 
supported. This code is included in CPT code 80307; therefore, it cannot be separately reimbursed. This code is 
not separately reimbursed when billed for specimen validity testing on urine specimens utilized for drug 
testing. Based on this information, we decided that Medicare rules for coverage of the laboratory service have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service (83789) 
provided August 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on July 26, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on July 
26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 83970, 84100) provided May 
2, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation submitted did not include a valid physician order/lab requisition or medical records 
supporting provider intent to order the test billed; therefore, the billed codes cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (82310, 83970, 84100) 
provided May 2, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve laparoscopic Roux-en-Y gastric bypass (RYGBP) surgery. 
 
You asked the Plan to pre-approve RYGBP surgery. You say that the clinical information provided supports 
the need for the requested surgery and shows the severity of the enrollees gastroesophageal reflux disease 
(GERD). The Plan denied your request. The Plan says that repeat bariatric surgery is generally not considered 
reasonable and necessary by Medicare. 
 
The Plan must follow Medicare rules. The rules say that repeat bariatric surgery can be covered when clinical 
circumstances demonstrate reasonability and necessity. 
 
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 RYGBP surgery. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee had esophageal manometry 
which demonstrated presence of GERD and 9 episodes of regurgitation, many of which correlated with GERD. 
The enrollee had gotten down to 300 pounds (lbs) from a high of 495 lbs but has regained to 421 lbs. He has a 
BMI greater than 35, the presence of an obesity-related complication (hypertension requiring multiple 
medications and still above 140/80). He has had a prior traumatic injury that makes exercise challenging. The 
surgery is 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 RYGBP surgery have been met. Therefore, we decided that the Plan has to pre-
approve laparoscopic Roux-en-Y gastric bypass (RYGBP) surgery.  
 
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 pre-approve an upper partial denture (D5225).

You asked the Plan to pre-approve an upper partial denture. You say that you are requesting a reconsideration
of the Plan's 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 based on a lack of information. The Plan
requested a reopening and stated that this request exceeds your benefit limits. The Plan is correct 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 May 27, 2020. Therefore,
we decided that the Plan does not have to pre-approve an upper partial denture (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SIJ injection. 
 
You asked the Plan to pre-approve the SIJ injection. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 SIJ injection. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that clinical findings and the imaging study results suggest lumbar spinal stenosis with 
radiculopathy as a possible cause of their lumbosacral pain. The review has determined that the enrollee does 
not meet the LCD coverage criteria. 
 
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 SIJ injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a SIJ injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 7, 2023. 
 
You asked the Plan to pay for procedure code 81345. The Plan denied your request. The Plan says payment for 
code 81345 is bundled into payment for code 0089U.  
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 7, 2023.