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

 
We decided that the Plan does not have to pay for the genetic testing provided on December 12, 2022, billed 
with codes 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's 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 
December 12, 2022, billed with codes 81314 and 81345.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 2, 
2023. 
  
You asked the Plan to pay for procedure code 99100. You say that the anesthesia services are covered under 
the surgeons and facilities authorizations. You say that the enrollee chose an in-network surgeon and facility 
and should not be penalized for an out of network anesthesia provider. The Plan denied your request. The Plan 
says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313),
electronic connection (E2311), a power seat elevation system (E2300), and a cup holder (K0108) for the
enrollee.
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, a power seat
elevation system, and a cup holder. You say that these items are medically necessary. The Plan denied your
request. The Plan says that the enrollee can operate the approved power options through their own switches and
the other items are not medical in nature.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness and electronic connection. Our Medical Director states that the available documentation
supports that the enrollee has upper extremity strength and function that are adequate to control power options
using their own switches. Our Medical Director found that the enrollee's condition does not meet criteria for
coverage of an expandable controller, harness, and electronic connection.
We looked at this physician's review, the file, and Medicare rules. A power seat elevation system and a cup
holder are not primarily medical in nature. Based on this information, we decided that Medicare rules for
coverage of an expandable controller, harness, electronic connection, a power seat elevation system, and a cup
holder have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable
controller (E2377), harness (E2313), electronic connection (E2311), a power seat elevation system (E2300),
and a cup holder (K0108) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies (electrodes) (A4595) provided to the enrollee on August 27, 2022.
You asked the Plan to pay for the electrodes. You say that it is impossible for the enrollee to initiate and continue treatment without prescribed supplies (A4595) as device's design function for treatment require said supplies for regimen. The Plan denied your request. The Plan says that the provider has not submitted any evidence that they have been contacting the member before shipping additional supplies. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the electrodes begin dispensed. Based on this information, we decided that Medicare rules for coverage of the electrodes have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (electrodes) (A4595) provided to the enrollee on August 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377) and 
the transfer handles (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and transfer handles. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
requested upgraded electronics are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.    
 
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 upgraded electronics and transfer 
handles. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has adequate upper body strength to 
manage the standard power drive controls. 
 
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 upgraded electronics have not been met. The requested transfer handles do 
not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-approve the upgraded 
electronics (E2311, E2313, E2377) and the transfer handles (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for electrodes or supplies (A4595) provided on October 19, 2022.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus partially overturned the Plans denial. The Plan requested a reopen and noted that the enrollee's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items. The records provided are not complete and do not meet these requirements.
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. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of these supplies have been met. Therefore, we decided that the Plan does not have to pay for electrodes or supplies (A4595) provided to the enrollee on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown (D2954), 
core buildup (D2950) retainer crown-porcelain fused to high noble metal (D6750) provided on January 25, 
2023. 
 
You asked the Plan to pay for prefabricated post and core, core buildup and retainer crown. You say that this 
should be covered. The Plan denied your request. The Plan says prefabricated post and core and a core buildup 
are not a covered service. The Plan also says that for dental conditions that have two or more possible 
treatments, the Plan will cover the lowest cost treatment, as long as it is proven to provide satisfactory results. 
If you choose to receive a higher cost treatment, you will be responsible to pay for the difference. The Plan already approved D6792 so since you chose to receive a higher cost treatment, you will be responsible to pay 
for the difference. 
 
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 
prefabricated post and core in addition to crown (D2954), core buildup (D2950) retainer crown-porcelain fused 
to high noble metal (D6750) provided on January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 9, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that these supplies were medically necessary. The Plan denied your request. The Plan says that the provider did not submit any evidence that they have been contacting the member before shipping additional supplies. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the electrical stimulator supplies being dispensed. Based on this information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 9, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab.  
 
You asked the Plan to pre-approve pembrolizumab. You say that pembrolizumab is medically necessary 
because the enrollee has olioprogression of the adenocarcinoma. The Plan denied your request. The Plan says 
that pembrolizumab is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 pembrolizumab. Our reviewer says that 
pembrolizumab is medically necessary. Our physician reviewer found that the requested drug pembrolizumab 
is FDA-approved. The drug pembrolizumab is also 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 pembrolizumab have been met. Therefore, we decided that the Plan has to pre-
approve pembrolizumab.  
 
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 pay for alveoloplasty services (D7320) provided on November 10, 
2022. 
 
You asked the Plan to pay for 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 the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
alveoloplasty services (D7320) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), a complete 
mandibular denture (D5120) and alveoloplasty (D7310 x4). 
 
 You asked the Plan to pre-approve the dental services. You say that the wrong code was entered, and the 
request was denied in error. You say that this error is denying you the coverage you should have been getting a 
long time ago. The Plan denied your request. The Plan says your benefit for dentures has already been 
exhausted. The Plan also says alveoloplasty is not a covered benefit.  
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on June 27, 2023 when the Plan authorized 
an immediate maxillary denture (D5130) and an immediate mandibular denture (D1540). Alveoloplasty is not 
among the services covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture (D5110), a complete mandibular denture (D5120) and alveoloplasty 
(D7310 x4).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 80 additional home health skilled nursing visits 
(G0299). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
medically stable and has a healing wound which does not require skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 80 additional home health skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months of continued use of a ventilator 
(E0466). 
 
You asked the Plan to pre-approve continued use of a ventilator. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued use of a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 

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 continued use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records 
document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode which is a modality which could be provided by a bilevel positive airway pressure (BiPAP) 
device with AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) months of continued use of a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 9, 2022.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the provider has not submitted any evidence that they have been contacting the enrollee before shipping additional supplies.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid due to a lack of documentation showing the enrollee was contacted prior to shipment. Medicare rules for coverage of these supplies have not been met.
Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for electrical stimulator supplies provided on September 26, 2022.
You asked the Plan to pay for these supplies . You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted there is no documentation to show contact with the enrollee prior to shipping the supplies.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, there is no documentation of prior contact with the enrollee before the supplies were shipped. Medicare rules for coverage of these supplies have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulator supplies provided to the enrollee on August 27, 2022.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the provider did not submit any evidence that they have been contacting the enrollee before shipping additional supplies.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, there is no documentation the enrollee was contacted prior to the supplies being shipped, as is required by Medicare. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies provided to the enrollee on August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided on February 3, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images and comprehensive oral 
evaluation. You say that you were not aware of the restrictions. The Plan denied your request. The Plan says 
your benefit for the intraoral - complete series of radiographic images has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - complete series of radiographic images  was exhausted on date of service 
October 22, 2021. Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of 
radiographic images (D0210) provided on February 3, 2023.