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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 16, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that kindly find the attached 
documents for review which proves the medical necessity for the billed services and process your claims for 
payment. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 Tissue Next testing (81479) provided on
December 4, 2021.
You asked the Plan to pay for this testing . 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 billed a unique
identifier of Z00D0. Review of the Medicare guidance and Diagnostics Exchange Registry does not show
Z00D0 as a covered code for 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 as billed due to an error with the unique
identifier code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided
that the Plan does not have to pay for Guardant360 Tissue Next testing (81479) provided on December 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical, multiple post collar, occipital/mandibular
supports, adjustable (L0180) provided on October 26, 2022.
You asked the Plan to pay for this item. You say that the neck brace was medically necessary. The Plan denied
your request. The Plan says that the documentation submitted did not sufficiently support the billed supply
code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid
physician order, proof of delivery and relevant medical records which support medical necessity.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The medical records provided do not discuss the need for this item. The record shows that the Plan
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the
Plan does not have to pay for the cervical, multiple post collar, occipital/mandibular supports, adjustable
(L0180) provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) x3 provided on March 14, 2023, to March 22, 2023. 
 
You asked the Plan to pay for dental services provided on March 14, 2023, to March 22, 2023. You say that 
you do not agree with the denial of the services you received. The Plan denied your request. The Plan says your 
benefit for the requested item or service 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 Plans coverage rules apply in this case. This benefit includes the 
requested D0350 but is limited to one per 36 floating months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received one covered 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350) on date of service March 14, 2023. Therefore, this benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350) x3 provided on March 14, 2023, to March 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 31, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 31, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 31, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of July 31, 2023, forward. Our physician reviewer found as 
of the last covered day, there is no indication in the available medical records that the enrollees psychiatric 
symptoms could not be managed on a less restrictive basis. As of the last covered day the enrollee did not 
express any active suicidal ideation or intent, or any intent to harm themselves or anyone else. The enrollee was 
not exhibiting any other significant symptoms such as psychosis or mania. The enrollee had no acute 
psychiatric issues that would require continued inpatient care beyond July 31, 2023. The enrollee has chronic 
symptoms. The available medical records do not support that continued inpatient care will change these 
symptoms or the enrollees current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 31, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 31, 2023, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) and nutritional counseling 
for control of dental disease (D1310) provided on April 12, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of dental services 
you received. The Plan denied your request. The Plan says these services are not covered under your Plan. 

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. Oral hygiene instructions and 
nutritional counseling for control of dental disease are not covered under the Plan's dental benefits. 
 
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 oral 
hygiene instructions (D1330) and nutritional counseling for control of dental disease (D1310) provided on 
April 12, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a percutaneous vertebral augmentation (PVA) (22514). 
 
You asked the Plan to pre-approve the PVA. You say that the enrollee's pain is at a 10 out of 10. You also say 
that this is not improving with conservative therapy. The Plan denied your request. The Plan says that this 
procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 PVA. Our reviewer says that the 
requested PVA is considered medically reasonable and necessary in this case. Our physician reviewer found 
the documentation indicates the injury occurred on April 6, 2023. The reviewer found that the imaging showed 
subacute vertebral fracture on May 12, 2023. The reviewer found that recent American College of Radiology 
(ACR) studies show minimal risk with retropulsed fragments. Therefore, the reviewer found that the requested 
PVA is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PVA have been met. Therefore, we decided that the Plan has to pre-approve 
a percutaneous vertebral augmentation (PVA) (22514).  
 
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 pre-approve vertebroplasty (22513, 22514). 
 
You asked the Plan to pre-approve vertebroplasty. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that both PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions when certain criteria 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 vertebroplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of other plausible causes of pain in the lumbar spine. 
Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebroplasty (22513, 22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic teeth #'s 18, 20, 29,
and 31 (D6740), pontic - porcelain/ceramic teeth #'s 19 and 30 (D6245), and core buildup, including any pins
when required for tooth #29 (D2950)
You asked the Plan to pre-approve these services. You say that this service will benefit the enrollee. The Plan
denied your request. The Plan says that these services are not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for crowns on teeth
#'s 18, 20, 29 and 31, pontics for teeth #'s 19 and 30 and core buildup for tooth #29. Our Medical Director
states that the documentation does not support that the Plan's coverage criteria were met in this case. There is
insufficient documentation demonstrating that the requested dental services were medically reasonable and
necessary. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of
these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a retainer crown - porcelain/ceramic teeth #'s 18, 20, 29, and 31 (D6740), pontic -
porcelain/ceramic teeth #'s 19 and 30 (D6245), and core buildup, including any pins when required for tooth
#29 (D2950)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 27, 2022, and
billed under code 87798.
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 as payment for code 87798 is included with
the payment of codes 87801 and 87150. Maximus overturned the Plans denial for insufficient claim
information in the case file showing payment of these codes. The Plan requested a reopen and provided the
required documentation.
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, payment of code 87798 would be included the payment for codes 87801
and 87150 also billed on the same date of service. Medicare rules for payment of this code are not met.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 27,
2022, and billed under code 87798.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided to the enrollee on September
27, 2022, under codes 96367, 96374, and 93005.
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 partially overturned the Plans
denial. The Plan requested a reopen and provided documentation of payment for codes 72131 and 72192.
Regarding codes 96367, 96374, and 93005, the rules say that A/B Medicare Administrative Contractors
(MACs) (B) may not pay for the technical component (TC) of radiology services furnished to hospital patients.
We find that the Professional Component/Technical Component (PC/TC) indicator for codes 96367 and 96374
is 5, which means these services cannot be paid in the facility setting. Therefore, we decided that the Plan does
not have to pay for codes 96367 and 96374. We find that the PC/TC indicator of code 93005 is 3, which means
it's a code that is TC only. Since this is a professional claim in a facility setting, the TC is not payable to the
physician in that setting. Therefore, we decided that the Plan does not have to pay for diagnostic services
provided to the enrollee on September 27, 2022, under codes 96367, 96374, and 93005.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided on August 17, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says as secondary payor at the time of service, the Plan must have proof the primary payor has addressed this claim. Maximus overturned the Plans decision. The Plan requested a reopen and provided additional information. The Plan shows documentation of attempts to work with the primary payor to review this claim.
The Plan notes they have reached out to obtain the Explanation of Benefits from the other insurance carrier, but the documentation has not been obtained at this time. The primary payor has indicated it can take up to 30 days or more to receive this information. The Plan notes once this information is submitted by the primary payor, the Plan will process the claim to see if any secondary payment is due.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary payor. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has provided documentation to show they have made several attempts to get the necessary claim review information from the primary payor. As the secondary payor, the Plan cannot be held responsible for these services until the primary payor has reviewed and either paid or denied the claim for these services. Therefore, we decided that the Plan does not have to pay for medical services provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 13, 2023, billed with 
codes 81227, 81231, 81232, 81291, 81306, 8335 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test is medically necessary and is 
supported in the medical record. 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 
January 13, 2023, billed with codes 81227, 81231, 81232, 81291, 81306, 8335 and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a coronary catheter (C1761) billed for dates of service from May 11, 2022, to May 12, 2022 under code 93458.
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 explanation of their decision. The Plan requested a reopen and provided additional information. The Plan noted that the acceptable code pairs for C1761 were 92928, 92933, 92943, C9600, C9602, and C9607. The Plan provided the "Offset Codepair" sheet listed in the IOCE Quarterly Data Files V23.1 under the "Report-Table" folder. In the code pair sheet, Column B shows the pass-through device code C1761. Column C clearly identifies 92928, 92933, 92943, C9600, C9602, and C9607 as the appropriate corresponding codes for pass-through code C1761. As code 93458 was not on that list, it was not an appropriate code to bill, and the denial was correct.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, code 93458 is not listed as an acceptable code for this service.
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a coronary catheter (C1761) billed for dates of service from May 11, 2022, to May 12, 2022, under code 93458.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the addition, endoskeletal system, below knee (BK), alignable 
system (L5910). 
 
You asked the Plan to pre-approve the alignable system. You say that you have attached an affirmation letter 
stating that the enrollee does meet the medical necessity requirements  The Plan denied your request. The Plan 
says that the alignable system is not a necessary part of the replacement socket.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 alignable system. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found it is highly unusual for a Plan to approve a replacement socket but specifically deny a small, 
inexpensive constituent part that is essential to the use of device. Given that the medical record overall has been 
deemed to be sufficient to cover the replacement socket generally, it creates an undue burden, which is not 
supported nor called for in Medicare policy, on the Beneficiary to demand that the record specifically address a 
small subpart of the overall approved service which neither a prosthetist nor a prescribing physician would 
think to speak to in the creation of authentic medical records. In situations where Congress or Medicare have 
seen fit to specifically regulate certain subparts of an overall DMEPOS device, they write statutes/regulations 
governing those codes expressly.  No such regulations exist governing the use of L5920 in either the LCD 
L33787 or in the Policy Article A52496.  Moreover, this part is not usually recycled between sockets precisely 
because it is laminated directly into the structure of the previous socket; a new alignable system is necessary 
every time a new lower extremity prosthetic socket is fabricated. Therefore, L5920 is hereby approved.  
 
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 alignable system have been met. Therefore, we decided that the Plan has to 
pre-approve the addition, endoskeletal system, below knee (BK), alignable system (L5910).  
 
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.