Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record show that the enrollee had a percutaneous computed tomography 
(CT) guided lung biopsy. This may be safely performed with a 24- 48-hour observational stay. Inpatient 
admission is not 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 29581 billed for July 8, 2022 under Claim A.
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 provided additional information. The Plan demonstrated that this claim denied because this service was not billed with the appropriate modifier. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states, "Casting/splinting/strapping CPT codes shall not be reported for application of a dressing after a therapeutic procedure." Per the operative report the multi-layer compression system of the lower leg was performed at the same location as the therapeutic skin substitute application.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Based on the medical records provided, these services were not billed with the appropriate modifier. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for code 29581 provided on July 8, 2022, under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller
(E2377), and expandable controller harness (E2313) for the enrollee.
You asked the Plan to pre-approve an electronic connection, expandable controller, and expandable controller
harness. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not
medically necessary for the enrollee. Maximus overturned the Plan's denial. The Plan requested a reopening
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, expandable controller, and expandable controller harness. Our Medical Director states that the
limited clinical documentation in the case file does not support that an electronic connection (E2311),
expandable controller (E2377), and harness (E2313) were medically reasonable and necessary for the enrollee
in this case. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an
electronic connection, expandable controller, and expandable controller harness.
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 electronic connection, expandable controller, and expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), and expandable controller harness (E2313) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment 
supported crown (D6058), provided on October 25, 2022. 
 
You asked the Plan to pay for D6057 and D6058. You say that you need this dental work because you are 
having a hard time swallowing. The Plan denied your request. The Plan says D6057 and D6058 are not covered 
benefits. 
 
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, 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 a custom 
fabricated abutment (D6057), and an abutment supported crown (D6058), provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a water circulating heat pad with pump (E0217). 
 
You asked the Plan to pre-approve a water circulating heat pad with pump. You say that the enrollee's 
medically necessity actually meets the guidelines that qualify for coverage. The Plan denied your request. The 
Plan says the requested water circulating heat pad with pump is non-covered because it is not considered 
medically necessary and non-medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a water circulating heat pad with pump (E0217).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee is unstable while walking. The Plan denied your request. The Plan says that the coverage criteria has not been met. Maximus overturned the Plan's denial. The Plan requested a reopening 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 IRF care.
Our Medical Director states that the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, and that she required treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program, and that there was a reasonable expectation that she would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing coded 80307, and the mass spectrometry services coded 83789 provided on July 26, 2022.
You asked the Plan to pay for either of these services. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus partially overturned the Plans denial and overturned code 80307. The Plan requested a reopen and stated that the medical records provided are insufficient and do not support the services billed.
The Plan is correct in this case. 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. In this case the Medicare rules were not met for code 83789 for mass spectrometry and the records provided are insufficient to show the criteria required for 80307 for drug testing. Therefore, we decided that the Plan does not have to pay for drug testing coded 80307, and the mass spectrometry services coded 83789 provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infrared therapy (97026). 
 
You asked the Plan to pre-approve infrared therapy. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT code 97026 Infrared is not covered per 
NCD 270.6 Infrared Therapy Devices. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve infrared therapy (97026).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint injections. 
 
You asked the Plan to pre-approve lumbar facet joint injections. You say that the lumbar facet joint injections 
are medically necessary. The Plan denied your request. The Plan says the requested facet joint injections do not 
meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 lumbar facet joint injections. Our 
reviewer says that the requested lumbar facet joint injections are not considered medically necessary in this 
case. Our physician reviewer found in this case, the enrollee has radiculopathy and non-facet pathology per 
clinical assessment and radiological studies that could explain the source of the enrollees pain (lumbar spinal 
stenosis on MRI). The review has determined that the requested facet joint injections do not meet the Medicare 
LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81225) provided on December 22, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial and request 
reconsideration of payment on this claim. You also say this is an important test that is needed to analyze 
clinically important genetic variations that may affect the enrollee's response to psychiatric medications. The 
Plan denied your request. The Plan says without medical records, a review to determine medical necessity 
cannot be conducted. 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 genetic testing have been met. The 
records show that medical records were requested twice from the ordering provider and records were not 
received. LCD L38337 says that the requested test must demonstrate analytical validity, clinical validity, and 
clinical utility to be considered reasonable and necessary for coverage. This is demonstrated through a required 
technical assessment of the test. Therefore, we decided that the Plan does not have to pay for genetic testing 
(81225) provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on February 08, 
2023. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $15 
copayment for podiatry services. 
 
You have been asked to pay a $15 copayment for podiatry services. This item/service falls within the podiatry 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for podiatry services provided 
on February 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a complete 
series of radiographic images (D0210), and prophylaxis (D1110), provided on December 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that there are no in-network providers locally. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a 
complete series of radiographic images (D0210), and prophylaxis (D1110), provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
sensor. You asked the Plan to pre-approve a Dexcom G7 CGM sensor. You say that the enrollee has been diagnosed 
with diabetes mellitus. You disagree with the denial. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for approval of the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 CGM sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 continuous glucose monitor (CGM) sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on January 24, 2023.  
 
You asked the Plan to pay for the dental service represented by code D0210. You say that you were expecting 
these charges to be a 0% cost for you under your dental plan. The Plan denied your request. The Plan says any 
service not specifically listed in the coverage information are not covered under the 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 an 
intraoral - complete series of radiographic images (D0210) provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
December 30, 2022. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should only have a 
$10 copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for the specialist office visit provided on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 provided on December 22, 2022. 
 
You asked the Plan to pay for procedure code 99214. 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 covered as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that the office visit was billed with one or more 
diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes indicate 
laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to bill a 
left and right sided diagnosis code when a bilateral code is available as in this case. Therefore, we decided that 
the Plan does not have to pay for procedure code 99214 provided on December 22, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on June 23, 2022.
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 coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that this claim denied because this service was not billed with the appropriate diagnosis code. Screening for abdominal aortic aneurysm in men of age greater than or equal to 65 years and less than 76 years is only allowed if there is a family history of abdominal aortic aneurysm or a smoking history. Per review of the claim this was billed with diagnosis code Z13.6 (Encounter for screening for cardiovascular disorders) which does not indicate the criteria of a family history of abdominal aortic aneurysm, a man aged 65 to 75 who has smoked at least 100 cigarettes in his lifetime, or other risk factors recommended. The records provided do not show the enrollee met the required criteria when the test was given.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of screening. The medical records provided do not show the enrollee met the required criteria at the time of the screening. Medicare rules for coverage of these services were not met. Therefore, we decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) x2 and gingival irrigation - per quadrant 
(D4921) provided on December 14, 2022. 
  
You asked the Plan to pay for dental services. You say that your insurance should reimburse you $86.00. The 
Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) and 
gingival irrigation - per quadrant (D4921) are not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4381 and D4921are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 
(D4381) x2 and gingival irrigation - per quadrant (D4921) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the interrogation device evaluation 
provided on January 18, 2023. 
 
You asked the Plan to waive the copayment for the interrogation device evaluation. You say that you do not 
agree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $5 
copayment for other outpatient diagnostic tests. 
 
You have been asked to pay a $5 copayment for the interrogation device evaluation. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the interrogation device evaluation provided on January 18, 2023.