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

We decided that the Plan does not have to pre-approve acupuncture for neck treatment.
You asked the Plan to pre-approve acupuncture for next treatment. You say that acupuncture is medically necessary. The Plan denied your request. The Plan says the required coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.
The Plan is correct in this case. Medicare covers limited acupuncture for chronic low back pain. The Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers acupuncture for chronic low back pain. This request is for acupuncture for neck pain. It should also be noted the Plan indicates you were told you could pre-pay this service and submit up to $150 of this treatment under your wellness benefit, however you chose not to do so. Therefore, the Maximus rationale that this should be applied to the wellness benefit does not apply. Based on this information, we decided that Medicare rules for coverage of acupuncture have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture for neck treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390, 99199), 
 
You asked the Plan to pay for the oxygen concentrator . You say that the item should be covered. The Plan 
denied your request. The Plan says the provider is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390, 99199),
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81201, 81408, 81406, 81479, 81432, 81403 and 81404) provided to the enrollee on June 15, 2022.
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. The Plan denied your request. The Plan says that screening genetic testing is not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81201, 81408, 81406, 81479, 81432, 81403 and 81404) provided to the enrollee on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for an office visit coded as 99215 provided on May 2, 2022.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met due to the omission of the KX modifier. The Plan states code 99215 was billed with a diagnosis
code of D05.12 Intraductal carcinoma in situ of left breast and C50.922 Malignant neoplasm of unspecified site
of left male breast for a transgender patient. This service is not typically performed for an enrollee whose
gender is male and was not billed with the appropriate modifier. The Plan states a corrected claim would be
reviewed if submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code and when necessary, with the appropriate modifier. In
this case, this claim could not be paid as billed due to the omission of the required KX modifier. Medicare
billing criteria were not met. Therefore, we decided that the Plan does not have to pay for an office visit billed
under code 99215 provided on May 2, 2022.
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 February 28, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. 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 February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
9, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on November 1, 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 claim was not billed with the appropriate DEX-Z code. Maximus overturned the Plans denial of insufficient information in the case file. The Plan requested a reopen and provided documentation to show the DEX-Z code billed, Z00DO, is not a valid code.
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 Z00D0 is not a valid DEX-Z code based on the "Guardant 360 TissueNext (Reflex)" registry information. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q0092 billed for date of service March 4, 
2023.  
 
You asked the Plan to pay for procedure code Q0092. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code Q0092 is 2. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code Q0092 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code Q0092 billed for date of service March 4, 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 you suffered a humerus fracture and need to receive 
therapy services to return to your prior level of function. The Plan denied your request. The Plan says you do 
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 that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone, is unable to get out of bed 
independently, and will require continued therapy to discharge safely to the community. The Plan denied your 
request. The Plan says admission to a SNF is 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 pre-approve 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service January 13, 
2023.  
 
You asked the Plan to pay for procedure code 76642. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis (L1686), and pelvic control, hip joint range of motion (ROM) (L2624) provided to the enrollee on July 8, 2022.
You asked the Plan to pay for the hip orthosis and pelvic control, hip joint range of motion. You say that these items were medically necessary. The Plan denied your request. The Plan says the documentation requirements have not been met.
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 records provided do not mention the need for the hip orthosis and pelvic control, hip joint range of motion or any condition that requires these items. 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 hip orthosis (L1686), and pelvic control, hip joint range of motion (ROM) (L2624) provided to the enrollee on July 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The 
documentation does not support that the enrollee has tried and failed zoledronic acid. The documentation does 
not support that zoledronic acid would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service March 24, 
2023.  You asked the Plan to pay for procedure code 88291. You say that the services were necessary for the 
enrollee's well being. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88291 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not include sufficient evidence to show that the excess 
units were medically necessary. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88291 billed for 
date of service March 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 71260, Q9967, and 74178.
You asked the Plan to pay for this claim as billed. You say that these services should be paid by the Plan. 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 stated that while they agree computed tomography exams were performed of the thorax and abdomen/pelvis on the billed date of service, the incorrect code was billed by the provider. The billed code states that contrast material was used during the exam. Per the medical records submitted only non-contrast technique was utilized. There is a separate code that should be billed when contrast is used during the exam. In addition, the Maximus decision agrees that contrast was not administered.
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, this claim could not be paid as billed due to an error with codes billed for the service reported. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic services billed to the enrollee for codes 71260, Q9967, and 74178 billed for date of service August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this device will provide the enrollee with the 
required support. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose and the enrollee's needs could be met by a bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
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 needs to be seen by a physician daily for 
pain management due to new amputation as well for management of IV antibiotics. The Plan denied your 
request. The Plan says the enrollee's records do not show that you will be able to participate in the intensity of 
services of an IRF actively and safely. 
 
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 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. 
 
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: 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 inpatient therapy would minimize the risk of falls 
and strengthen you. The Plan denied your request. The Plan says your records do not show that you need an 
intensive team for your care. Services needed may be provided safely in a lower level of care. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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.