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

 
We decided that the Plan does not have to pre-approve 9 months continued use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9 months continued use of a ventilator. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan 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. 
 
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 9 months continued use of a ventilator. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found continuation of 
the home ventilator is not medically necessary. If this enrollee does have chronic carbon dioxide (CO2) 
retention, it appears the enrollee's needs could be met with bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep.  Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP.  Of note, the plan has approved the ventilator for an 
additional 3 months to allow time for transition to BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 months continued use of a ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 9 months continued use of a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bi-level positive airway pressure (BiPAP) device (E0471) 
heated humidifier (E0562). 
 
You asked the Plan to pay for the BiPAP device. You say that the enrollee has been using the machine since 
December 6, 2022. Please approve the authorization so the enrollee can continue to use the machine. The Plan 
denied your request. The Plan says documentation was not provided that support that the medical necessity 
criteria has been met. 
 
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 the BiPAP device have been met. The 
provided records consisted of only a 1-page compliance report. Additional records were needed and requested 
to support medical necessity. The records show that the Plan made multiple attempts to obtain the needed 
medical records from the provider without success. Therefore, we decided that the Plan does not have to pay 
for bi-level positive airway pressure (BiPAP) device (E0471) heated humidifier (E0562).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 for date of service August 6, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that 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. In this case, the CPT Code Manual definition of 
code 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes 
are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder 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 procedure code 99223. Our reviewer says that the 
documentation supports the code billed. Our reviewer found the enrollee had a history of chronic pain 
syndrome on narcotic therapy, hypertension, and hypothyroidism and sustained a fall at home resulting in a 
right hip fracture. The documentation supports a comprehensive history a comprehensive examination and 
medical decision making of high complexity. Therefore, code 99223 is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99223 for date of service August 6, 2022.  
 
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 issue reimbursement for the fitness bike purchased on October 25, 2021.
You asked the Plan to issue reimbursement for the fitness bike. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this item is not a covered benefit. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus applied the incorrect criteria.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan cover up to $400 for a fitness tracker and/or a membership in a qualified health club or fitness facility.
The Plan's rules for coverage have not been met because there is no benefit for fitness equipment. Therefore, we decided that the Plan does not have to issue reimbursement for the fitness bike purchased on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies not used with an external infusion pump (A4223) provided from July 5, 2022, to July 12, 2022.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and demonstrated that the code billed is not used with an external infusion pump and the guidelines require the use of the GY modifier.
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 was not billed with the appropriate code or modifier required by Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the infusion supplies not used with an external infusion pump (A4223) provided from July 5, 2022, to July 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested drug is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollees diagnosis. The use of Keytruda is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 for date of service September 8, 2022. 
 
You asked the Plan to pay for procedure code 99236. 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. 
 
In this case, the CPT Code Manual definition of code 99236 is observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit.  
We asked our coder 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 procedure code 99236. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee was treated for generalized 
weakness. The documentation from that date states that the enrollee presented with weakness and a workup 
was essentially unremarkable. The enrollee was treated with IV fluids and placed on observation status then 
discharged home stable. Although there was a brief history and detailed physical exam documented, there was 
no documentation of medical decision-making of high complexity to justify the code, 99236. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99236 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99236 for date of service September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 billed for date of service June 5, 2022. 
 
You asked the Plan to pay for procedure code 99236. 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 a PC/TC Indicator of 0 indicates a physician 
service code. Modifiers 26 & TC cannot be used with these codes. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99236 have not been met. Specifically, we find that the procedure code at issue has 
a PC/TC Indicator of 0. The code was incorrectly reported with a 26 modifier to indicate a professional 
component. Therefore, we decided that the Plan does not have to pay for procedure code 99236 billed for date 
of service June 5, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $180 more for the eyewear. We decided that the Plan does not have to fully 
pay for the eyewear.  
 
  You asked the Plan to pay more for the progressive lens (V2781), polycarbonate or equal (V2784), anti-
reflective coating (V2750), and deluxe frame (V2025) provided on January 20, 2023. You say that you would 
like the enrollee to be reimbursed for their out-of-pocket charges for the glasses. You also say that you and the 
enrollee approve of the Plan deducting the amount of $313.99 from the yearly $750 allowance. The Plan says 
that this claim was processed correctly. The Plan also says the transaction was denied at the eye care provider's 
because the merchants code does not fit with the Plan's Flex Visa program approved transactions for hearing, 
dental, and optical.  
 
We decided that the Plan has to pay $180 more for the eyewear.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a $300 for eyewear every year. 
 
We looked at the file and the Plan's rules. The provided documentation does not show that the Plan paid the full 
$300 allowance toward the enrollee's eyewear purchase. Specifically, the information submitted supports that 
the Plan only paid $180 toward the eyewear provided on January 20, 2023. Your Evidence of Coverage clearly 
states that you have a $300 benefit per calendar year for eyewear. Based on this information, we decided that 
the Plan's rules for coverage of the eyewear have been met. Therefore, we decided that the Plan has to pay $180 
more for the eyewear.  
 
We also decided that the Plan does not have to fully pay for the eyewear. 
 
We looked at the file and the Plan's rules. The record shows that he Plan only paid $180 for this eyewear 
purchased on January 20, 2023, and we have decided that the Plan must pay an additional $120 for the 
eyewear. This would exhaust the enrollee's $300 eyewear benefit. Based on this information, we decided that 
the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not 
have to fully pay for the eyewear. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service April 28, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the claim for the molecular pathology 
testing denoted by code 87631 did not include the required unique identifier. Codes 94761 and 99072 are not 
separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that providers must report 
services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met. Additionally, we find that procedure code 94761 has a status indicator of T on the Physician 
Fee Schedule. The case record shows that other payable services were billed on the same date by the same 
provider. This means that procedure code 94761 is not separately payable in this case. We also find that 
procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that procedure 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 94761 and 99072 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 87631, 94761 and 99072 billed for date of service April 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) (93702) for the enrollee.
You asked the Plan to pre-approve BIS. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve BIS. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. The medical literature indicates that bioimpedance analysis is a potential tool with demonstrated benefits for prevention of chronic breast cancer-related lymphedema (BCRL) and may be an economic and great alternative for early diagnosis of BCRL. Our physician reviewer found that the enrollee's condition meets criteria for coverage of BIS. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BIS have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) (93702) for the enrollee.
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 the periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110) and unspecified preventive procedure, by report (D1999) provided on June 8, 2022.
You asked the Plan to pay for the dental services. You say that the Plan has always paid for your dental checkups with this provider, so you do not understand why they are not covering this visit. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional documentation.
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 dental services was exhausted on date of service April 28, 2022. The Plan provided documentation (Explanation of Benefits) confirming they covered $1,000 towards dental services prior to you receiving services on June 8, 2022. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110) and unspecified preventive procedure, by report (D1999) provided on June 8, 2022.
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. The Plan denied your request. The Plan says this request cannot 
be approved for you. 
 
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. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 3, 2022, to 
February 25, 2022. 
 You asked the Plan to pay for the home health services. You say that you do not believe this claim should be 
denied in full.  You believe that it should only be subject to a penalty. 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 February 3, 2022. The NOA was not received by the Plan until March 28, 
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 
from February 3, 2022, to February 25, 2022.