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

 
We decided that the Plan does not have to pre-approve an outpatient percutaneous vertebral augmentation at 
T12. 
 
You asked the Plan to pre-approve an outpatient percutaneous vertebral augmentation. You say that the 
enrollee needs this procedure. The Plan denied your request. The Plan says the enrollee does not meet 
evidence-based criteria as at T11-T12. 
 
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 an outpatient percutaneous vertebral 
augmentation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation is not evident regarding a 
progression of the body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a 
severe impact on her daily activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient percutaneous vertebral augmentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an outpatient percutaneous vertebral 
augmentation at T12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat liner and head rest cover (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the headrest cover does not serve a primary medical purpose. The seat liner 
cannot be use for components of the wheelchair seat cushion. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The head rest cover in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The approved 
seat cushion includes all parts needed to work properly. The requested seat liner cannot be used with the seat 
cushion. Therefore, we decided that the Plan does not have to pre-approve a seat liner and head rest cover 
(K0108x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found large volume, long-term/high-quality 
clinical studies do not confirm the clinical benefits (ultimate outcomes of functional improvement and pain 
reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. No compelling rationale or extenuating circumstances are presented to support the medical necessity of this request 
as an exception. Therefore, the requested computer-assisted navigation 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computer-assisted surgical navigation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair (K0861) and attachments.
You asked the Plan to pre-approve these services. You say that you cannot walk at all or use your arms and have a bad back. The Plan denied your request. The Plan says that the requested power wheelchair exceeds your needs and is not reasonable and necessary, per Medicare criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 power wheelchair (PWC) and attachments. Our Medical Director states that the available clinical medical records do not support that a Group 3 Power Wheelchair with power tilt and recline options and power elevating leg rests is medically reasonable and necessary for 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair (K0861) and attachments.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is experimental when used as bone graft material. 
 
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 aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 12, 2022, billed 
with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81314, 81334, and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
December 12, 2022, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81314, 
81334, and 81345.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hereditary cancer risk panel testing (81432 and 
81433). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 services. Our physician reviewer 
found there is no clinical data to determine medical necessity. There are no records to state if you have a 
personal history of breast cancer or if your daughter is available for testing or has had testing and has a BRCA 
mutation. The service is not reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the hereditary cancer risk panel testing (81432 and 81433).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 27, 2022, and billed under codes 87641, 87150, 87481, 87653 and 87798.

You asked the Plan to pay this claim. 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 denial was due to PTP code edits with codes 87150 and 87801 and not for PTP edits with code 87500. 
The Plan demonstrated that codes 87150 91 (7 Units), 87481 (1 Unit), 87653 (1 Unit) and 87798 91 (12 Units) are not supported. These codes are included in the payment of code 87500 and cannot be separately reimbursed. The Plan also notes the medical records do not contain sufficient information to support the codes billed. There is no documentation which identifies the organisms represented by code 87150. There is also no indication a repeat clinical laboratory test was performed. This means modifier 91 was not used appropriately. 

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 codes and when necessary, the appropriate modifiers.  In this case, this claim could not be paid due to the submission of codes whose payment is already included in code 87500 which was paid by the Plan and the use of a 91 modifier which is not supported by the medical records. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 27, 2022, and billed under codes 87641, 87150, 87481, 87653 and 87798.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 19, 2022, billed under code 81455. 

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. The Plan requested a reopen and stated that this was a billing error and not a coverage error. The Plan notes that e this service was inappropriately billed as the provider should have billed code 81479, based on the records provided. 

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, the Plan has demonstrated code 81479 should have been billed instead of code 81455.  Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 19, 2022, billed under code 81455.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and used for 
patients being treated for chronic pain. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311), a harness 
(E2313), an expandable controller (E2377), and an accent color wheel insert (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and accent color wheel insert. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says it is not necessary to 
control the power options through the joystick. The Plan also says that the accent color wheel insert does not 
service a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose.   
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage the standard power 
drive controls. 
 
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 upgraded electronics have not been met. An accent color wheel insert does 
not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection device (E2311), a harness (E2313), an expandable controller (E2377), and an accent color wheel 
insert (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 20, 2022, and billed under code 88329 under Claim A.
You asked the Plan to pay Claim A. You say that this claim should be paid. The Plan denied your request. The Plan says this code was previously paid to the same provider group. Maximus overturned the Plans denial for insufficient claim information in the case file showing previous payment. The Plan requested a reopen and submitted the required claim information.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this code cannot be paid as billed on Claim A, due to its previous billing and payment by the same physician group on Claim B.
Without the modifier required to identify this as a separate and distinct service, Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 20, 2022, and billed under code 88329 under claim number FLA 69289935-00 (Claim A).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient L4 kyphoplasty (22514). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says per LCD, back pain not primarily due to the Vertebral Compression 
Fracture is an absolute contraindication to this procedure. 
 
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 service. Our physician reviewer 
found detailed documentation is not evident regarding worsening pain, a progression of the 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 the low back pain. Therefore, the medical records provided do 
not meet the requirements listed in the LCD for Medicare coverage. 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 service 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the outpatient L4 
kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, knee disarticulation, 
expandable wall socket (L5653) and an addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845). 
 
You asked the Plan to pre-approve prosthetic parts. You say that the enrollee has special needs for her 
prosthetic and needs one that seals inside, and not outside, in order to fit properly for her residual limb. The 
hydraulic control feature to the knee is needed for safety, and to add stability. The Plan denied your request. 
The Plan says the requested prosthetic parts exceed the enrollee's need. The approved knee already has the 
stance feature requested. The part of the socket is for a knee disarticulation, which the enrollee does not have. 
 
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 prosthetic parts. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided medical records document the enrollee has an above the knee amputation 
(transfemoral amputation) not a knee disarticulation. Also, the stance flexion feature (L5845) does not meet 
Local Coverage Article Lower Limb Prostheses - Policy Article A52496 criteria for approval as stance phase 
control is already included in the approved knee unit L5828. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic parts have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower extremity, knee disarticulation, expandable wall socket (L5653) and 
an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 3, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says that since the provider is renting the TENS Unit to the member the provider should not bill for supplies. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the unit are included in the rental allowance and there is no additional allowance for items such as electrodes, lead wires, and batteries. We looked at the file and Medicare rules. The file indicates the provider is renting the enrollee a TENS unit. Medical rules indicate that there is no additional allowance for items such as electrodes, lead wires and batteries during TENS unit rental. Based on this information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on September 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on March 2, 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 this service is not a covered benefit.  
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29530 and A6456 billed for date of service 
July 8, 2022. 
 
You asked the Plan to pay for procedure codes 29530 and A6456. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 29530 is 
bundled into payment for code 20610. Additionally, procedure code A6456 was billed with the incorrect place 
of 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, we have confirmed that code 29530 
is a column II code to column I code 20610. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, CPT code A6456 has a status code of "X" under the Physician Fee Schedule and 
represents a service that is not in the statutory definition of "physician services" for fee schedule payment 
purposes. 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 codes 29530 and A6456 billed for date of service July 8, 2022.