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

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service August 7, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 code 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented with 
nausea/vomiting/diarrhea with abdominal/flank pain consistent with a Crohn's flare-up. The history was 
detailed. Physical findings were detailed and described abdominal tenderness. The vitals were stable, and 
workup without signs of infection. CBC without leukocytosis, ESR slightly elevated, CRP normal. She was 
treated with IV fluids and pain control and was discharged home. Although the history and physical were 
detailed, the documentation did not clearly show medical decision-making of high complexity. Therefore, code 
99285 is not supported. 
 
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 code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service August 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network diagnostic radiology services provided on January 28, 2022.

You asked the Plan to pay for these services. You say that this claim should be paid.  The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. Maximus overturned the Plans denial. The Plan requested a reopen and provided confirmation that the enrollee was not referred for these services by an Plan provider. 

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 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 out of network diagnostic radiology services provided on January 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code J3490 was billed to identify Bupivacaine. This drug is a local anesthetic, which is not 
separately billable. 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 procedure code J3490 
billed for date of service February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment.  The Plan denied your request. The Plan says radiographic evidence does not correlate with 
predominant physical complaints.  
 
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous basivertebral 
nerve is only covered under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for vertebrogenic low back pain. The requesting provider states 
that Modic changes are noted at L3, L4, L5, and S1. However, the formal MRI reading does not demonstrate 
Modic changes at any level other than L3-4. Additionally, there are multiple plausible pathologic sources of 
significant pain generation. The aching low back pain, noted pain-aggravating factors (activity), pain-relieving 
factors (rest), and intact neurologic exam were/are all non-specific to any pathologic entities. Overall, the 
documentation is lacking regarding reasonably detailed and evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. The 
documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous basivertebral nerve ablation in this case is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine dental services provided on October 26, 2022. 
 
You asked the Plan to pay for routine dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 pay for routine 
dental services provided on October 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 10, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on January 24, 2023. 
 You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care provided on January 24, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on November 07, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 outpatient mental 
health visit provided on November 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
23, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on December 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 13, 2022. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a computerized knee and replacement foot
(L5950, L5856, L5828, L5848, L5845, L5980, L5986).
You asked the Plan to provide coverage for a computerized knee and replacement foot to include several
accessories. You say that these prosthetics are medically necessary. The Plan denied your request. The Plan
says Medicare coverage criteria are not met. Maximus upheld the Plans denial. Upon quality review the case
was reopened to include the above regulations for prosthetic equipment and equipment less than five years old.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for prosthetic equipment.
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 this request. Our reviewer says that the requested prosthetic
equipment is not considered medically reasonable and necessary in this case. Our physician reviewer found a
computerized knee and replacement foot exceed your medical needs, as Medicare does not pay for any items or
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve
the functioning of a malformed body member. In addition, your current knee and foot are less than five years
old and are still under warranty. Medicare coverage criteria for the requested equipment are not 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 a computerized knee and replacement foot and accessories are not met.
Therefore, we decided that the Plan does not have to provide coverage for a computerized knee and
replacement foot (L5950, L5856, L5828, L5848, L5845, L5980, L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 15, 
2022.  
You asked the Plan to pay for subsequent nursing facility care. You say that the claim should be reprocessed. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on October 14, 2022. 
 
You asked the Plan to pay for the heat pad with pump. You say that the item at issue was medically necessary 
for the efficacy of the treatment rendered. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the heat pad with pump have not been met. Therefore, we decided that the Plan does not have to 
pay for the water circulating heat pad with pump (E0217) provided on October 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health care office visit provided 
on December 23, 2022. 
 
You asked the Plan to waive the copayment for the mental health care office visit. You say that you only see 
the doctor for 45 minutes, and you should only have a $40 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 $100 
copayment for in-network outpatient mental health care provided by an outpatient hospital. 
 
You have been asked to pay a $100 copayment for the mental health care office visit. This item/service falls within the in-network outpatient mental health care provided by an outpatient hospital benefit category. 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. The records show the 
services were provided by an outpatient hospital, and the copayment was applied correctly. Therefore, we 
decided that the Plan does not have to waive the copayment for the mental health care office visit provided on 
December 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 30, 2022, to July 
5, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported correctly. The Plan denied your request. The Plan says the diagnosis 
codes of A41.9 (Sepsis, unspecified organism) and J96.01 (acute respiratory failure with hypoxia) are not 
supported in the medical record. Therefore, the DRG has been changed from 871 to 194. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 (Sepsis, unspecified organism) and J96.01 
(acute respiratory failure with hypoxia). 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 the 
inpatient hospital services at the DRG originally billed. Our reviewer says that these diagnoses are not 
supported in the medical record. Our physician reviewer found that in this case there was no clinical or 
laboratory evidence of sepsis. Regarding the enrollee's respiratory status, the arterial blood gases recorded on 
presentation were acknowledged with the PaO2 57 on room air, and the hospital correspondence stating "P/F 
ratio of 271 with Pa O2 57 on room air," however, the value was unclear as the enrollee was noted to have 
malignant pleural effusion at baseline, and in the setting of chronic lung disease and/or lung infection, there 
was no clinical or laboratory evidence of acute respiratory failure with hypoxia. The review has determined 
that the documentation did not support A41.9 (Sepsis, unspecified organism) and J96.01 (acute respiratory 
failure with hypoxia).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 30, 2022, to July 5, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (CT) scan of the
lungs for the enrollee.
You asked the Plan to pre-approve a low dose computed tomography (CT) scan. You say that this is medically
necessary. The Plan denied your request. The Plan says that there is no need for a repeat scan. Maximus
overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct
criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a low dose
computed tomography (CT) scan. Our Medical Director states that a CT lung cancer screening without contrast
was performed on July 19, 2022 and is available for review in the re-opening request. There were no suspicious
pulmonary nodules were identified. Granulomatous calcifications were noted. A 12-month screening chest CT
was recommended. The additional documentation submitted supports that it was not reasonable to repeat a CT
scan of the chest in the enrollee in this case. Our Medical Director found that the enrollee's condition does not
meet criteria for coverage of a low dose computed tomography (CT) scan.
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 low dose computed tomography (CT) scan have not been met. Therefore, we
decided that the Plan does not have to pre-approve a low dose computed tomography (CT) scan of the lungs for
the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 6, 2022, to 
February 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you made numerous attempts to 
submit a timely NOA. You believe this claim should be paid. The Plan denied your request. The Plan says the 
claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 6, 2022, to 
February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for a leadless pacemaker provided to the enrollee on July 8, 2022.
You asked the Plan to pay for these services . You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for
medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the fact that
the claim was not submitted with the required modifier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules state that providers must
submit claims appropriately. In this case, this claim could not be paid due to the omission of a required
modifier. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for a
leadless pacemaker provided to the enrollee on July 8, 2022.