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

We decided that the Plan does not have to provide coverage for an electrical connection to control one power feature through the wheelchair controller (E2310).
You asked the Plan to provide coverage for the requested accessories. You say that you say that this accessory was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic connection device (E2310). The Maximus Physician Reviewer determined that the enrollee could not weight bear through the right upper extremity due to a history of trauma and required assistance with transfers. It was noted that the enrollee had 0/5 motor strength in the left upper extremity.
The enrollee could not perform pressure relief independently due to weakness and required a power wheelchair with power tilt for adequate pressure relief and positioning. The complexity of his seating and positioning needs necessitates a more complex group 3 power wheelchair base. "The requested controller is necessary to operate the group 3 power wheelchair base and the power tilt option." The Plan requested a reopen and stated the medical records show the enrollee has adequate right upper limb strength and function to be able to control the power option using its own switch which is included in the allowance of this power option. The medical records show the enrollee has left-sided hemiplegia secondary to a stroke. On September 28, 2022, right upper extremity muscle testing was 4/5 with full range of motion possible with moderate to almost full resistance by examiner. Muscle testing on the left was 0/5. The Plan is correct in this case. The documentation supports that the enrollee has upper extremity strength and function that are adequate to control power options using their own switches. 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 requested accessories have not been met. Therefore, we decided that the Plan does not have to provide coverage for an electrical connection to control one power feature through the wheelchair controller (E2310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for the electrical stimulator supplies provided September 28, 2022.
You asked the Plan to pay for this claim. You say that the Plan should pay for these supplies. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the provider billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The Medicare billing guidelines state a separate allowance will be made for replacement supplies when they are reasonable and necessary and are used with a covered TENS. The usual maximum utilization is 2 TENS leads, a maximum of one unit of A4595 per month and 4 TENS leads, a maximum of two units of A4595 per month. The Provider is billing the units more than the Medicare allowed amount.
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 be paid as billed due to the number of units billed on the claim. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes B4197, B4224, and B4220 provided on 
April 12, 2023. 
 
You asked the Plan to pay for procedure codes B4197, B4224, and B4220. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
supported. 
 
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 procedure codes B4197, B4224, and 
B4220 have been met. There were no records provided with an April 12, 2023, date of service. Therefore, we 
decided that the Plan does not have to pay for procedure codes B4197, B4224, and B4220 provided on April 
12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on January 30, 2023, 
to March 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services (D2950) provided on January 30, 2023, to March 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for code 93971-RT-26 billed for July 29, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided a copy of the claim previously billed for code 92971.
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 MUE for this code. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 93971-RT-26 billed for date of service July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
February 22, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the chiropractic manipulative treatment 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
 
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 this service. Our reviewer says that the 
chiropractic manipulative treatment provided was not medically necessary. Our physician reviewer found that 
in this case, the record indicates that you have received chiropractic treatment. The records provided do not 
document the presence of a subluxation of the spine either by physical examination or radiographic images. 
The elements of the coverage criteria are not satisfied. The service provided is not 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatment (98941) provided on February 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 14, 2022, to 
November 10, 2022.  
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the NOA was 
not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 31, 2022. The NOA was not received by the Plan until November 
17, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on October 14, 2022, to November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records we received do not show that you need a doctor to monitor your care at least 
three days per week. In addition, the records do not show that you need a medical team to manage 
your health care decisions. Your needs can be met at a lower level of care such as a skilled 
nursing facility or home health 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspiration remains experimental in spine surgery. More research is 
needed to show safety and efficacy when used as bone graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power 
option (K0861) and accessories (E1012, E2311, E0956, E2607, E2361, E2377, E2313, E1028x2, E1007, 
E2620, E0955, K0108x3). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you need the requested 
wheelchair immediately. The Plan denied your request. The Plan says you do not meet criteria for approval of 
the requested wheelchair. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have diabetes and sarcoidosis. You do not have neuropathy, 
myopathy or a congenital spinal deformity which is required per LCD 33789. The requested wheelchair is not 
medically 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power option 
(K0861) and accessories (E1012, E2311, E0956, E2607, E2361, E2377, E2313, E1028x2, E1007, E2620, 
E0955, K0108x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planning (D4341) for the upper and lower left quadrants.
You asked the Plan to pre-approve the dental services. You say that you need this service to save your teeth. 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service April 22, 2022.
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planning (D4341) for the upper and lower left quadrants.
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 February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. 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 
February 27, 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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99152) provided on February 20, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99152 is Moderate 
sedation services provided by the same physician or other qualified health care professional performing the 
diagnostic or 
therapeutic service that the sedation supports, requiring the presence of an independent trained observer to 
assist in the 
monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice 
time, patient age 5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not support 
that a trained observer was present. Based on this information, we decided that Medicare rules for coverage of 
the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (99152) provided on February 20, 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 necessary for the procedure to be 
done inpatient and to receive therapy services. 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: 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 5, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. 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 
5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 for date of 
service March 20, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the documentation shows that outpatient intravenous insulin treatment (OIVIT) either pulsatile or 
continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea 
nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. There is a more appropriate code to be billed for the services rendered; therefore, code 96365 cannot be 
verified. 
 
The medical records indicate that OIVIT either pulsatile or continuous, by any means, guided by the results of 
measurements for: respiratory quotient; and or, urine urea nitrogen (UUN); and or, arterial, venous, or capillary 
glucose; and or potassium concentration was performed. There is a more appropriate code to be billed for the 
services rendered; therefore, code 96366 cannot be verified. 
 
The medical records submitted show that OIVIT was performed and does not include a procedure report for 
pump maintenance refill. This means code 96521 cannot be verified. 
 
The medical records show that Nova R was administered via intravenous treatment. There is a more 
appropriate code to be billed for the services rendered; therefore, code J1815 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 96365, 96366, 
96521, and J1817 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 96365, 96366, 96521, and J1817 for date of service March 20, 2023.