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

 
We decided that the Plan does not have to pre-approve extra covering for a prosthetic leg (L5962). 
 
You asked the Plan to pre-approve the services. You say that there is a clicking noise in the food indicating that 
something is broken, and the outer layer has tears in it. The Plan denied your request. The Plan says this request 
exceeds the enrollee's needs. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the patient has a need for protection  of harsh environmental 
conditions or requires specialized protection beyond a standard protective cover. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extra covering for a prosthetic leg (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital observation provided on September 10, 2023, to 
September 11, 2023. 
 
You asked the Plan to pay for the hospital observation. You say that you are requesting reconsideration stating 
please review medical records showing medical necessity and process payment. 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 the hospital observation 
provided on September 10, 2023, to September 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine care facility visit provided on August 22, 2023. 
 
You asked the Plan to pay for the routine care facility 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 the routine care facility 
visit provided on August 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service September 30, 2022. 
 
You asked the Plan to pay for code 99285. You say that the patient's presentation supports a high-risk level, so 
code 99285 was billed correctly.  The Plan denied your request. The Plan says code 99285 is not supported by 
the medical record. The documentation supports code 99284 instead because the records only substantiate 
moderate medical decision making. 
 
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. 
 
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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the medical records do not support the level of 
complexity for medical decision making required for this code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a pneumatic compression device (E0652) for
the enrollee.

You asked the Plan to provide coverage for a pneumatic compression device (E0652). You say that at the time
of the appeal, this device was medically necessary.

The Plan denied your request. The Plan says the 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 noted that the request was for approval of a segmental pneumatic compressor device (PCD) E0652 and
associated appliances. The clinical documentation indicates the enrollee is diagnosed with venous insufficiency
and hereditary lymphedema. The records show the enrollee has truncal edema and tried a basic pump for 20
minutes without improvement. The supplied documentation does not support completion of a 4-week trial of a
basic pump.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare has specific coverage criteria for this device. Based on the records
provided, the enrollee did not fully meet all of the required criteria at the time of the appeal. Therefore, we
decided that the Plan does not have to provide coverage for a pneumatic compression device (E0652) for the
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 heavy duty, multiple 
power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds and accessories. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the services are 
medically necessary The Plan denied your request. The Plan says the services are not 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 the durable medical equipment (DME). 
Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair, group 3 heavy duty, multiple power 
option, sling/solid seat/back, patient weight capacity 301 to 450 pounds and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory analyses provided on August 02, 2023. 
 
You asked the Plan to pay for the laboratory analyses. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory analyses 
provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the observation care evaluation and management services described by 
codes 99225 billed for date of service September 15, 2022, and 99217 billed for date of service September 16, 
2022. 
 
You asked the Plan to pay for 99225 and 99217. You say that 99225 and 99217 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says that 99225 and 
99217 are denied because the records dont indicate the enrollees status was designated or admitted for 
observation. 
 
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 codes 99225 billed for September 15, 2022, and 99217 billed for September 16, 2022, are 
supported in the medical record. Specifically, we confirmed that the claim for 99225 and 99217 was billed with 
place of service 22, indicating an on-campus outpatient hospital setting, which is appropriate for observation 
care. The provided records do not contain any evidence or indication that the enrollee was admitted to the 
hospital as inpatient or converted to inpatient status prior to or on the dates of service in question. Based on this 
information, we decided that Medicare rules for coverage of 99225 and 99217 have been met. Therefore, we 
decided that the Plan has to pay for the observation care evaluation and management services described by 
codes 99225 billed for date of service September 15, 2022, and 99217 billed for date of service September 16, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36140 rendered on December 23, 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 Current Procedural Terminology (CPT) code 36140 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 36140 is ""Introduction of needle or intracatheter, upper 
or lower extremity artery." 
 
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 at issue is whether the 
documentation supports use of code 36140. A review of the medical records submitted does not reveal sufficient documentation to use the code 36140 (1 unit). 
 
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 procedure code 36140 rendered on December 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the onabotulinumtoxina injection provided 
on July 19, 2023. 
 
You asked the Plan to waive the coinsurance for the onabotulinumtoxina injection. You say that you do not 
agree with the copayment amount for this service. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the onabotulinumtoxina injection. This item/service falls 
within the Medicare Part B prescription drugs 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 total you owe is $322.54 ($1,612.72 allowed amount x 20% = 
$322.54). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
onabotulinumtoxina injection provided on July 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a L4-L5 posterior fusion and Stabilink device. 
 
You asked the Plan to pre-approve the arthrodesis. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says experimental and investigational procedures are not covered. 
 
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 arthrodesis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a L4-L5 posterior fusion and Stabilink device is considered experimental/investigational 
and is not medically necessary for the treatment of chronic low back pain. 
 
 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 arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a L4-L5 posterior fusion and Stabilink device.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from July 6, 2023, to July 21, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that the NOA was not received timely. As such, this final claim 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial indicates that the NOA was not received timely. The Plan did 
not provide a copy of the untimely NOA. It is the Plan's responsibility to support its denial with evidence. In 
this case, the Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the Plan 
has to pay for home health services provided from July 6, 2023, to July 21, 2023.  
 
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 mandibular and maxillary partial denture (D5225,
D5226).

You asked the Plan to pre-approve the dental services. You say that the services should be covered as you
disagree with the 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 because of a lack of information.
The Plan requested a reopening and stated that this benefit was exhausted. 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 July 1, 2020. Therefore,
we decided that the Plan does not have to pre-approve a mandibular and maxillary partial denture (D5225,
D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on August 14, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that please see attached medical records. This was a 
medical necessity and provider saw enrollee in good faith.  The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) provided on 
August 14, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 7, 
2023.  
 
You asked the Plan to pay for procedure code 85060. You say that the services at issue were a medical 
necessity for the enrollee. 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 85060 is 1. The MAI value for this code is 3. You billed 2 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 85060 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 85060 billed for date of service August 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 30, 2023, to 
September 28, 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 August 30, 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 August 
30, 2023, to September 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for July 1, 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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 10061 
provided on June 28, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99283 billed for 
July 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 11, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have attached medical records for review. 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 the office visit provided 
on October 11, 2023.