Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service June 11, 2023. 
 
You asked the Plan to pay for code 99233. You say that the code billed is reflective of the high medical 
decision making involved. The Plan denied your request. The Plan says code 99233 is not supported by the 
medical record. As a result, this service was down-coded to 99232. 
 
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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 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 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the interval history and physical were not appropriate 
given the number of overnight events that are noted to have occurred. The medical decision making was not of 
high complexity.  As such, the billing of CPT 99233 for this date of service s 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 code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service June 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in appropriate condition 
for transfer to a LTACH. The Plan denied your request. The Plan says the LTACH services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee should only require short-term additional acute care services that can be 
done safely at the facility being provided by the health Plan. Transfer to the LTACH is not medically necessary 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended.  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to provide coverage for Envarsus for the enrollee under Medicare Part B.

You asked the Plan to provide coverage for Envarsus under Medicare Part B. The Plan denied your request.
The Plan says the enrollee is not eligible for this to be covered under Medicare Part B, due to her non-Part A
eligibility and how the transplant was paid. Maximus upheld the Plans decision. After additional information
was received from your office, Maximus chose to look at the case file again and get confirmation from the Plan
regarding how the transplant was covered as that affects how this drug is covered.

The Plan must follow Medicare rules. The rules say that immunosuppressive drugs prescribed due to transplant
are covered under Medicare Part B if the enrollee was Medicare Part A eligible then the transplant occurred.
The records show the enrollee is not Medicare Part A eligible. Therefore, the transplant would not have
been covered by Medicare as transplants are covered as a Part A benefit. We sent a request for
information to the Plan to confirm how the transplant was covered. The Plan responded and noted that that
review of their records show the Plan paid for the enrollee's transplant under their "Medicare
replacement plan" therefore, the uphold for coverage of this drug would be correct.

The Plan notes the enrollee does not have Part D coverage through the Plan and would need to request
coverage through their Part D carrier for this drug. Therefore, we decided that the Plan does not have to provide
coverage for Envarsus for the enrollee under Medicare Part B.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 1, 
2023, to June 30, 2023. 
 You asked the Plan to pay for SNF care. You say that admission to a skilled nursing facility was medically 
necessary. The Plan denied your request. The Plan says admission and stay at a skilled nursing facility was not 
medically necessary. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from June 1, 2023, to June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with options/accessories. 
 
You asked the Plan to pre-approve power wheelchair. You say that this is needed to meet the enrollee's needs. 
The Plan denied your request. The Plan says the Plan has confirmed that the enrollee is a resident in a skilled 
nursing facility (SNF); therefore, a power wheelchair is not separately covered in this location. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair with options/accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee requires LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation indicating medical necessity for admission to an LTACH. 
The enrollee does not require services at the LTACH level of care that are not available at the acute care 
hospital in which they are currently receiving care. The requested LTACH services are not medically 
appropriate for the diagnosis and condition of 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 22, 2022, 
to November 24, 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 the 
DRG billed was appropriate based on the medical records. The Plan denied your request. The Plan says the 
billed primary diagnosis code of N17.9 (acute kidney failure, unspecified), is not supported by the medical 
record. As a result, a lower DRG was paid. The medical records indicate that the enrollee's creatinine on 
admission was 1.7 and on discharge it was 1.2. Questionable chronic kidney disease was documented in the 
medical record. The lab values are not indicative of an acute kidney injury in this enrollee. 
 
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 primary diagnosis code N17.9 (acute kidney failure, 
unspecified). 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 the billed primary diagnosis code of N17.9 (acute kidney failure, 
unspecified) is not supported by the medical records. Our physician reviewer found the enrollee was 
hospitalized with a post-operative eye infection.  Laboratory studies showed mild kidney injury/dehydration, on 
top of suspected chronic kidney disease. There is no evidence that the enrollee had acute renal failure.  As such, 
the billing of N17.9 is not supported.  
 
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 November 22, 2022, to November 24, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for two magnetic resonance imaging (MRI)
scans provided on February 14, 2023.

You asked the Plan to waive these copayments. You say that you cannot afford this cost share. The Plan denied
your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct cost share.

The Plan is correct in this case. 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 $175 copayment for each radiological diagnostic services such as an MRI. The
fact that the provider billed one of the scans less than the other is in your favor.

The provider could have charged $175 for each scan as each scan was performed for a different purpose.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive charges for two magnetic resonance imaging (MRI) scans
provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second claim submitted for discharge day management
(code 99239) provided on July 22, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial for insufficient claim information in the file. The
Plan requested a reopen and provided additional information. The Plan provided documentation to show the
claims previously paid for this enrollee show a paid claim under 22K597144700 on date of service August 31,
022 to the same provider for code 99239. Two months later, on October 27, 2022, the same provider submitted
another claim for code 99239 under claim number 22N783851700 causing this to be a duplicate.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the billing of code 99239. Based on the claims submitted, the claim denied was billed a second time in error
by the same provider for the same enrollee. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for hospital inpatient or observation discharge day
management (code 99239) provided on July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Dexcom G7 sensors.

You asked the Plan to provide coverage for Dexcom G7 sensors. The Plan denied your request. The Plan says
all the required Medicare criteria are not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not follow the LCD criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs and related sensors (Dexcom G7 sensors) are considered medically reasonable and necessary for
enrollees with diabetes who use insulin with at least three daily administrations, require frequent selfadjustment
of insulin dosage based on the blood glucose testing results and have had an in-person visit with
their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. Based on the
medical records provided, you do not meet all of the criteria required by Medicare for approval of the requested
sensors. Therefore, we decided that the Plan does not have to pay for Dexcom G7 sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and
electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that
these items are medically necessary. The Plan denied your request. The Plan says that although there are three
approved power options on this wheelchair, there is not a medical need to control these power options through
the joystick.

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's upper extremity strength and function are adequate for her to control the power
options using their own switches. Consequently, the expandable controller, harness, and electronic connection
are not medically necessary for the enrollee in this case. 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. Based on this information, we decided that
Medicare rules for coverage of expandable controller, harness, and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness
(E2313) and electronic connection (E2311) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services billed to the enrollee for
December 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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan noted that the billing provider is not a recognized facility or a legally qualified physician. Billing agents
and third-party vendors do not fall within the category of eligible providers and services are not payable under
the Plan. In addition, the claim shows this non contracted provider is providing a service for the physician
and/or the facility, not at the request of our member. A review of the enrollee's claims shows that the Plan paid
for inpatient hospital admission services on date of service December 28, 2022, to December 29, 2022.
Payment was made for all services to the billing inpatient facility. Per Medicare rules, the Plan pays the facility
for all services provided during the inpatient stay. Payment for these services contracted by the facility should
be billed by the provider directly to the facility.

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, as the enrollee was an inpatient on the date of service, your claim for
payment should be submitted to the facility and not directly to the Plan. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for to pay for the
neuromonitoring services provided on December 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the enrollee does not meet every requirement for LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the acute hospital can provide for all the enrollee's present inpatient care needs. 
The enrollee is receiving an appropriate level of care in the present setting and the Plan has stated that 
continued care in the short-term acute hospital will be covered as is medically indicated. Continued care in the 
short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care, such as an 
inpatient rehabilitation facility, a sub-acute rehabilitation facility, or a skilled nursing facility. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a AmnioBand skin substitute (Q4151). 
 
You asked the Plan to pre-approve a AmnioBand skin substitute. You say that you are appealing the denial 
with supporting documentation. The Plan denied your request. The Plan says the requested skin substitute is 
not medically necessary. 
 
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 AmnioBand skin substitute. Our 
reviewer says that the requested item/service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested AmnioBand substitute application to the patients heel 
ulceration is not medically reasonable or necessary. The medical documentation supports that the patient is 
suffering with a right heel ulceration. Only two progress notes are provided, which discuss standard wound care, including debridement and dressing changes. It is unclear whether the ulcer to the posterior right heel is 
being offloaded with specialized pads and boots. In this case it does not appear that the ulceration has been 
given enough time to heal with standard wound care, including debridement and offloading. Furthermore, there 
is no discussion as to failure of a wound vacuum-assisted closure, which is also considered standard of care for 
deep ulcerations. 
 
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 AmnioBand skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a AmnioBand skin substitute (Q4151).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 13, 
2023, to April 9, 2023. 
 You asked the Plan to pay for SNF care. You say that a stay in a skilled nursing facility was medically 
necessary. The Plan denied your request. The Plan says a stay in a skilled nursing facility was not medically 
necessary. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 13, 2023, to April 9, 2023.