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

We decided that the Plan does not have to pay for code 99491 provided to the enrollee.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan
requested a reopen and provided additional information. The Plan noted that this claim denied because this
service was billed with an inappropriate diagnosis code. The Plan states the appealed claim was billed with
diagnosis code I10 for essential (primary) hypertension. However, 2 chronic conditions must be billed to use
this code per the Medicare guidance in MLN909188 for Chronic Care Management. The Plan notes that
eligible patients for chronic care management services must meet the following elements: multiple (two or
more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic
conditions that place the patient at significant risk of death, acute exacerbation or decompensation, or
functional decline, comprehensive care plan established, implemented, revised, or monitored; first 30 minutes
provided personally by a physician or other qualified health care professional, per calendar month. The records
provided do not support the claim billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes.

In this case, this claim could not be paid as billed due to the omission of an appropriate diagnosis code.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have
to pay for code 99491 provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator (E0466) for the enrollee.

You asked the Plan to pre-approve a ventilator. You say that the enrollee needs the ventilator because of the
backup battery, alarms, and option for secondary mode for ambulation and recovery features that a BiPAP does
not provide. The Plan denied your request. The Plan says that the request for continued use of non-invasive
ventilator is not medically reasonable and necessary. Maximus partially overturned the Plan's denial. The Plan
requested a reopening and states that the enrollee did not meet criteria for coverage.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as
not reasonable and 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 a ventilator. Our reviewer says that a
ventilator is not medically reasonable and necessary for the enrollee. This patient has a diagnosis of COPD and
has had a home ventilator since December 2020. An echocardiogram indicates the patient also has pulmonary
hypertension and right ventricular failure. There have been previous hospitalizations with blood gases
consistent with acute on chronic hypercarbic respiratory failure. The patient has improved with BiPAP in the
hospital in the past. There are no pulmonary function tests to assess the severity of the COPD. Use of the
current device from April 24, 2023, to May 23, 2023, shows 87% of days with at least 4 hours of use. It appears
this patient's respiratory support needs could be met with BiPAP with AVAPS during sleep. The records do not
show that this has been tried and failed as an outpatient. Medicare does not cover a home ventilator when used
at settings that can be provided with BiPAP. Our physician reviewer found that the enrollee's condition does
not meet Medicare criteria for a ventilator.

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 ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a ventilator (E0466) for the enrollee.
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 for the enrollee 
to receive medical management and rehabilitation to regain their maximum function. The Plan denied your 
request. The Plan says ongoing skilled care can be provided in an alternate setting.  
 
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 enrollee does 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the power scooter purchased on February 20, 
2023. 
 
You asked the Plan to reimburse you for the power scooter. You say that you need this device. The Plan denied 
your request. The Plan says a home assessment has not been completed to show there is adequate space in your 
home for the use of the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that prior to or at the time of delivery of a power operated 
vehicle (POV) or power wheelchair (PWC), the supplier or practitioner must perform an on-site evaluation of 
the beneficiarys home to verify that the beneficiary can adequately maneuver the device.  
 
The file does not support that a home assessment was performed. This means that Medicare rules for coverage 
of a PMD have not been met. Therefore, we decided that the Plan does not have to reimburse you for the power 
scooter purchased on February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network service was not pre-approved or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided on July 26, 2023, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided on August 1, 2023. 
 
You asked the Plan to pay for procedure code 99232. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 36514 
provided on August 1, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99232 provided on 
August 1, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for IV therapy. We decided that the Plan does not have to 
waive the cost share for a CT scan and an MRI.  You asked the Plan to waive the cost share for a CT scan, an MRI, and IV therapy provided from July 3, 2022, 
to July 4, 2022. You say that you disagree with the cost share applied. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to reduce the cost share for IV therapy.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). According to the explanation of benefits, the Plan charged 
you a $196.92 copayment IV therapy. However, the cost share for Medicare Part B prescription drugs, 
including IV therapy, is 20% coinsurance of the allowed amount. The allowed amount for the IV therapy 
service is $196.92 x 20% = $39.38. Therefore, we decided that the Plan has to reduce the cost share for IV 
therapy to $39.38.  
 
We also decided that the Plan does not have to waive the cost share for a CT scan and an MRI. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for diagnostic radiological services, including a CT and MRI. Therefore, we decided that the Plan 
does not have to waive the cost share for a CT scan and an MRI. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332) 
provided on June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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. 
 
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 24, 2023. 
Therefore, we decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior 
(D2332) provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS pulmonary pressure sensor. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this device due to 
worsening heart failure. The Plan denied your request. The Plan says that there is not enough medical proof to 
show the safety and/or success of CardioMEMS for heart failure monitoring and it is considered experimental 
and/or unproven. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS pulmonary pressure sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed for date of service February 23, 
2023, with codes 87532, 87496, 87798, 87486, 87581, 87640, 87541 and U0005. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory services billed for date of service February 23, 2023, with codes 
87532, 87496, 87798, 87486, 87581, 87640, 87541 and U0005.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoperative radiation therapy (IORT). 
 
You asked the Plan to pre-approve IORT. You say that this treatment is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 IORT. Our reviewer says that the 
requested IORT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found IORT with a portable LINAC or via electronic brachytherapy is not within accepted standards of care. 
The reviewer found there are multiple society statements and guidelines that advocate against these 
treatments. Therefore, the reviewer found that the requested IORT is not medically reasonable or 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 IORT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intraoperative radiation therapy (IORT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service August 4, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 81456 is bundled into payment for 
code 81455. 
 
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, we have confirmed that code 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81456 billed for date of service August 4, 2023.
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 SNF care is necessary. The Plan denied your 
request. The Plan says SNF care 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 there is no documentation that daily skilled services are required. You are 
walking household distances with a rolling walker with supervision and are supervised for transfers and 
activities of daily living. The provided records do not document a significant decline in your functional status 
compared to your recent baseline to necessitate daily inpatient skilled therapy services. There is no 
documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. The 
medical records do support that services in the home with home health care or in a long-term care facility on a 
part time basis are appropriate in this case. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyebrow/eyelid (blepharoplasty) surgery. 
 
You asked the Plan to pre-approve eyebrow/eyelid surgery. You say that the enrollee's visual fields are making 
daily activities difficult. The Plan denied your request. The Plan says the medical criteria for this procedure 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that surgical procedures of the eyelid/eyebrow may be 
covered if 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 eyebrow/eyelid surgery. Our reviewer 
says that the enrollee does not meet criteria for this surgery. Our physician reviewer found the marginal reflex 
distance is documented to be 3mm bilaterally. The visual fields do not demonstrate a superior field loss of 12 to 
15 degrees that improves with taping. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eyebrow/eyelid surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eyebrow/eyelid (blepharoplasty) surgery.
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 for the enrollee 
after their surgery as they are not ready to return home due to the need for therapy services. 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 enrollee does 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.