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

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 28, 2022.

You asked the Plan to pay for this testing. 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
DEX Diagnostic Exchange Registry shows DEX Z-Code ZBBIA has a coverage status of "Not Covered".
Per this Medicare guideline, the Plan denied the claim for payment the Z-Code ZBBIA is not covered for the
MoIDX program.

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 an error with the reported Z-code.
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not
have to pay for genetic testing provided to the enrollee on October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mito Genome Sequencing and Deletion testing (81460,
81465).

You asked the Plan to pre-approve the testing. You say that these services are medically necessary. The Plan
denied your request. The Plan says that this service is non-covered by Medicare. Maximus overturned the
Plan's denial. The Plan requested a reopening and stated that this was not denied for medical necessity but a
statutory exclusion from Medicare. The Plan is correct in this case. Medical rules state that genetic testing
procedures submitted under CPT codes 81460 and 81465 are unlikely to impact therapeutic decision-making in
the clinical management of the patient and will be denied automatically as not medically necessary. Based on
this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we
decided that the Plan does not have to pre-approve Mito Genome Sequencing and Deletion testing (81460,
81465).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve routine transportation. You say that you have an appointment with your 
established neurologist. The Plan denied your request. The Plan says that routine transportation beyond 50 
miles per one-way trip is not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles of driving distance per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. Transportation to this destination does not 
exceed 50 miles of driving distance per one-way trip. Based on this information, we decided that the Plans 
rules for coverage of routine transportation have been met. Therefore, we decided that the Plan has to pre-
approve routine transportation services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex care needs. The Plan denied your request. The Plan says when the enrollee is ready to 
leave the hospital, they can receive this care in another setting. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH 
that are not already available at the current facility. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S8948 billed for date of service May 24, 
2023. 
 
You asked the Plan to pay for procedure code S8948. You say that when you had these treatments, there was 
never a constant provider in attendance. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S8948 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S8948 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S8948 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S8948 billed for date of service May 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires rehab services to safely return 
home. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an 
IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no active medical complexity. Records do not show acute rehab nursing 
needs. At the current functional level the enrollee needs physical and occupational therapy services. Document 
does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, and 
nursing needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollees rehab needs can be safely provided in an alternate and low intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for bitewings (D0274) provided on August 14, 2023. 
 
You asked the Plan to pay for D0274. You say that you had no control over what the dentist did during the 
visit. The Plan denied your request. The Plan says that D0274 was previously provided. 
 
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 has failed to provide an evidence of benefit to verify that D0274 was 
previously provided in the last 12 months. Therefore, we decided that the Plan has to pay for bitewings 
(D0274) provided on August 14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 8, 2022, to July 
10, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were necessary and 
appropriate. The Plan denied your request. The Plan says there are insufficient records to support the services 
billed. However, the Plan has agreed to make partial payment. 
 
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 inpatient hospital services have been 
met. Specifically, no medical records were submitted for review. Without these records, we cannot verify that 
the services reported in the claim were rendered and billed appropriately, or that the diagnosis codes reported 
are supported. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided 
on July 8, 2022, to July 10, 2022, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 21, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the diagnosis codes are appropriate for the 
patient's condition. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that S82.92XA has an Excludes1 note in relation to S81.802A. This means that 
the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have 
to pay for ambulance services provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110), the oral examination 
(D0150), and the periapical x-rays (D0220, D0230) provided on August 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were given incorrect information 
about your options of dentists. You say you were not given updated information and that your dentist was out-
of-network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental cleaning (D1110), the oral 
examination (D0150), and the periapical x-rays (D0220, D0230) provided on August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on June 5, 2023. 
 
You asked the Plan to pay for core buildup. You say that this was medically necessary. 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 core 
buildup (D2950) provided on June 5, 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), the power elevating leg rest/platform (E1012), wheelchair cushion (K0669),
power seat elevation system (E2300) and a mudguard kit (K0108) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness, electronic connection, the power
elevating leg rest/platform, wheelchair cushion, power seat elevation system and a mudguard kit. You say that
you disagree with the denial and request reconsideration. The Plan denied your request. The Plan says that the
seat lift does not serve a primary medical purpose. Upgraded electronics (electronic connection, expandable
controller, and harness) cannot be covered per Medicare rules. The mud guards do not serve a medical purpose
and cannot be covered. Medicare rules say that non-approved wheelchair cushions cannot be covered.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness, electronic connection, the power elevating leg rest/platform and wheelchair cushion. Our
Medical Director states that the requested electronic connection, expandable controller, and harness cannot be
covered per Medicare rules. These items are necessary when there is a medical need to control multiple power
options though the joystick. In this case, only one power option has been approved. The clinical documentation
does not support that a power elevating leg rest/platform and wheelchair cushion are medically reasonable and
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, electronic connection, the power elevating leg
rest/platform and wheelchair cushion.

We looked at this physician's review, the file, and Medicare rules. The power seat elevation system and a
mudguard kit are not considered medical in nature. Based on this information, we decided that Medicare rules
for coverage of an expandable controller, harness, electronic connection, the power elevating leg rest/platform,
wheelchair cushion, power seat elevation system and a mudguard kit 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), the power elevating leg rest/platform (E1012), wheelchair cushion (K0669), power seat
elevation system (E2300) and a mudguard kit (K0108) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 58300 billed for date of service April 27, 
2023. 
 
You asked the Plan to pay for procedure code 58300. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the billed code is non-covered. 
 
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 58300 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 58300 is non-covered for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of procedure code 58300 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 58300 billed for date of service April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that you are requesting an expeditious reconsideration 
to further create a treatment plan for this enrollee. The Plan denied your request. The Plan says Medicare 
criteria is not met as the previous injection provided relief for less than one month. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI is covered when the criteria listed in the 
Medicare rules section are met. 
 
 
 
 
 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 repeat ESI. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no evidence to support the 
routine performance of a "series" of repeat injections without regard to the clinical response to an initial ESI. 
There is no documentation that the request is for a repeat injection using a different approach, level, and/or 
medication. The review has determined that the enrollee does not meet the LCD coverage criteria. 
 
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on May 24, 
2023. 
 
You asked the Plan to pay for a CGM. You say that the Plan should pay for this. The Plan denied your request. 
The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on 
May 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees current level of functioning requires minimum assistance for bed 
mobility, transfer, and ambulation of 20 feet with a rolling walker. The enrollee requires moderate assistance 
for sit and supine transfers. The review has determined that the complexity of the enrollee's nursing, medical 
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical or 
occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x6). 
 You asked the Plan to pre-approve home health services. You say that this is 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 documentation 
does not specify any acute clinical concerns, changes in plan of care or medications. The records do not show 
that 6 additional home health skilled nursing visits are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. 
 
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 home health skilled nursing (G0299 x6).