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

We decided that the Plan does not have to pre-approve an expandable controller upgrade (E2377), harness (E2313), electronic connection (E2311) and gel arm pads (K0108) for the enrollee.

You asked the Plan to pre-approve an expandable controller upgrade, harness, electronic connection and gel arm pads. You say that these items are medically necessary. The Plan denied your request. The Plan says that these items are medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller upgrade, harness and electronic connection. Our Medical Director states that the clinical documentation in the case file does not support that an electronic connection (E2311), expandable controller (E2377), and harness (E2313) were medically reasonable and necessary for the enrollee in this case. The upper limb strength and function appear to be adequate for the enrollee to control the power options using their own switches. Our physician reviewer found that the enrollee's condition does not meet criteria for an expandable controller upgrade, harness and electronic connection.

We looked at this physician's review, the file, and Medicare rules. Gel arm pads do not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of an expandable controller upgrade, harness, electronic connection and gel arm pads have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller upgrade (E2377), harness (E2313), electronic connection (E2311) and gel arm pads (K0108) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary overdenture (D5863) and a 
complete mandibular overdenture (D5865). 
 
You asked the Plan to pre-approve the overdentures. You say that your dentures are broken, they don't fit 
correctly and are throwing your bone structure off. You say it is hard to eat, they cause sores in your mouth, 
and you need them replaced as soon as possible. The Plan denied your request. The Plan says this service is not 
a covered expense under your dental plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 a complete maxillary 
overdenture (D5863) and a complete mandibular overdenture (D5865).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 10, 2023, to 
February 7, 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 the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 10, 2023. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered from January 
10, 2023, to February 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 21, 
2022, to November 23, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says these services have been denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found no atrial fibrillation was noted. There were no signs/symptoms or other serious 
condition was found on initial workup, and the enrollee responded to treatment. Based on the provided 
documentation, it was not expected that the enrollee would require hospital services that would likely cross two 
midnights at the time of admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided November 21, 2022, to November 23, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was medically necessary.  The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. 


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. The medical records show the enrollee had significant decline in her base line function and was not expected to either benefit from or be able to participate in at least three hours of therapy per day at least five days per week. 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 provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  additional chiropractic services. 

You asked the Plan to provide coverage for  additional chiropractic services. You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request. The Plan says the records show the $2000 benefit was exhausted prior to this request. Maximus overturned the Plans denial for insufficient information in the case file to show this benefit was exhausted. The Plan requested a reopen and provided the required information. 

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and benefit information. Your contract with the Plan clearly says that there was a $2000 maximum benefit for chiropractic services. The Plan provided documentation to show those services were exhausted prior to the appeal for continued services. Therefore, we decided that the Plan does not have to provide coverage for  additional chiropractic services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.

You asked the Plan to pre-approve SNF care. You say that at the time of the appeal SNF services were medically necessary.  The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. 

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The records clearly show the enrollee was admitted to the SNF as a long-term resident. The intended care was custodial which is not covered by Medicare.  Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service October 3, 2022.

You asked the Plan to pay for this service . You say that this claim should be paid by the Plan.  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 stated that Maximus did not apply the correct billing criteria. The Plan noted that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local
anesthetic agent that cannot be separately reimbursed from the injection procedure 27096 that was billed
on the same claim. Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable:
1. Use of local anesthesia;
2. IV start;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion; and
5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or
nonchemotherapy injection and infusion service. Per these Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service.

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 code. In this case J3490 could not be paid as billed since its payment is included in the payment for another code. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 21, 
2023.  
 
You asked the Plan to pay for procedure code 99458. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99458 is 3. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for December 5, 2022. 
 
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 procedure code 99204 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 99204 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 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that code 
99213 was billed on January 22, 2022 by the same provider group; therefore, a new patient office visit does not apply. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99204 billed for December 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 22, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 
81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 22, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81238.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 rendered on October 31, 2022. 
 
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 that Current Procedural Terminology (CPT) code 99223-AI (1 Unit) remains 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 99223 is "Initial hospital 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 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does support a 
comprehensive history, examination, and medical decision making of high complexity. The enrollee was 
brought into the hospital for urinary retention. The enrollee was found to have altered mental status. The foley 
was assessed, there was a swallow evaluation, and there was a physical therapy evaluation. The enrollee was 
started on IV fluids. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 99223 rendered on October 31, 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 pre-approve a crown for tooth number 14. 

You asked the Plan to pre-approve this service. You say that at the time of the appeal, this crown was medically necessary.  The Plan denied your request. The Plan says the Plans contractual coverage criteria for a crown were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria. The Plan states the dental records do not show the tooth has pathologic destruction such as caries or other trauma involving 4 or more surfaces and 2 or more cusps as required by the criteria. 

The Plan is correct in this case. Medicare 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 provided clearly show that you did not meet the Plans coverage requirements at the time of the appeal. 

Therefore, we decided that the Plan does not have to pre-approve a crown for tooth number 14.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62380 billed for date of service September 
22, 2022. 
 You asked the Plan to pay for procedure code 62380. You say that this code was reported correctly. The Plan 
denied your request. The Plan says this code is missing a necessary laterality modifier for payment and must be 
resubmitted with the appropriate LT, RT or 50 modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 62380 have not been met. Specifically, code 62380 has a bilateral surgery indicator 
of 1. This means that there is a payment adjustment depending on whether the procedure is bilateral or 
unilateral. This code was not reported with any of the laterality modifiers (LT, RT, or 50 in the case of bilateral 
services) to clarify the payment amount for this service. Therefore, we decided that the Plan does not have to 
pay for procedure code 62380 billed for date of service September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you feel the oxygen 
concentrator should be covered. The Plan denied your request. The Plan says the enrollee does not meet 
medical necessity of the requested device. 
 
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 portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a diagnosis of heart failure, asthma and hypoxemia. You are on 2 
liters supplemental oxygen, and you reportedly already have portable oxygen tanks. Based on the medical 
records provided, there is no documentation that the portable oxygen concentrator at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for you. Provided records in this case do not 
document necessity of the portable oxygen concentrator as opposed to the portable oxygen tanks which you 
reportedly already have. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power operated vehicle (K0820). 
 
You asked the Plan to pre-approve a group 2 standard power operated vehicle. You say that you feel unsafe to 
drive your scooter. The Plan denied your request. The Plan says your home does not have adequate access 
between rooms for a power wheelchair, and you cannot access the ramp in the back of your home. The Plan 
also says that a power wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (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 standard power operated 
vehicle. Our reviewer says that a group 2 standard power operated vehicle is not medically reasonable and 
necessary for you. Our physician reviewer found you have a scooter but do not use it in your apartment. You 
are able to walk 30 feet. Our reviewer found that your apartment is not accessible to a power wheelchair. Our 
physician reviewer also found that you do not require a power wheelchair to perform activities of daily living, 
and your living circumstances do not allow safe and reasonable use of the wheelchair 
 
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 2 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 standard power operated vehicle (K0820).