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

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 6, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service March 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service March 30, 2023. 
 
You asked the Plan to pay for procedure code 99285. 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented with pain after a 
fall. Evaluation by history, examination, plain x-rays and computed tomography revealed a left shoulder 
fracture dislocation which was reduced under anesthesia and evidence of a possible right patella fracture. The 
enrollee was stable in the emergency department after the reduction and was discharged to home on oral 
analgesics to follow-up with orthopedics. The documentation does not support a high level of medical decision 
making. Therefore, code 99285 is not 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 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acupuncture for eye and eyelid twitching.
You asked the Plan to provide coverage for acupuncture for eye and eyelid twitching. You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request.
The Plan says acupuncture is only covered for low back pain. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare and the Plan cover acupuncture for low back pain. This treatment is for eye twitching and eyelid twitching. This is not a diagnosis for which acupuncture is covered. Therefore, we decided that the Plan does not have to provide coverage for acupuncture for eye and eyelid twitching.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service January 10, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that based on the information provided, along 
with supporting documentation that clearly shows medical necessity, you request the Plan overturn the denial 
and reprocess the claim. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. This code was billed with the GZ modifier. All claim line(s) items submitted with a GZ 
modifier shall be denied automatically and will not be subject to complex medical review. 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 81345 billed for date of service January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740 x3), and core buildups (D2950 x3). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted with the Plan's approval of three crowns 
and three core buildups. Therefore, we decided that the Plan does not have to pre-approve additional crowns 
(D2740 x3), and core buildups (D2950 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request for continued use of a ventilator is 
not medically reasonable and necessary. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, with 
pulmonary function testing in 2019, showing mixed obstructive and restrictive lung disease with air trapping, 
with a forced expiratory volume (FEV1) of 37% of predicted. The home ventilator was prescribed in April 
2022, following hospitalization for acute on chronic hypercarbic respiratory failure. Device download covering 
July 13, 2023, to August 11, 2023, shows use for at least four (4) hours/day on 100% of days. The records do 
not show that bilevel positive airway pressure (BiPAP) with average volume-assured pressure support 
(AVAPS) has been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that 
can be provided with 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for physician services billed to the enrollee for September 19, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided information to show the enrollee was in a skilled nursing facility (SNF) for this service and the type of bill claim was also for SNF facility services.
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. Medicare rules state if the same physician or other supplier entity does not furnish both the technical component (TC) and professional component (PC) of a diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different payment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier "26" by the interpreting physician.
When the physician's interpretation of a diagnostic test is billed separately from the technical component, as identified by modifier -26, the interpreting physician (or his or her billing agent) must report the address and ZIP code of the interpreting physician's location on the claim form. As the CPT 71046 was billed without the required 26 modifiers; we find that Medicare rule for payment of CPT 71046 has not been met. In this case, this claim could not be paid as billed due to the omission of the required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee for September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device (E0730) provided to the enrollee on September 28, 2022.
You asked the Plan to pay for the TENS device. You say that this claim was billed correctly. The Plan denied your request. The Plan says that the trial period must be monitored by the treating practitioner to determine the effectiveness of the TENS unit in modulating the pain.
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 TENS device have been met. Current medical records have not been provided to confirm the TENS unit was still necessary for the enrollee's care. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device (E0730) provided to the enrollee on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87799 billed for date of service February 13, 
2023. 
 
You asked the Plan to pay for procedure code 87799. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87799 is bundled into payment for code 87798. 
 
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 87799 
is a column II code to column I code 87798. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. The -59 modifier is 
not supported as a separate and distinct procedural service. Therefore, we decided that the Plan does not have 
to pay for procedure code 87799 billed for date of service February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99397 billed for date of service December 9, 
2022. 
 
You asked the Plan to pay for procedure code 99397. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99397 is bundled into payment for code 
95004. 
 
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 99397 
is a column II code to column I code 95004. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 99397 billed for date of service December 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81599) provided to the enrollee on October 6, 2022.
You asked the Plan to pay for the laboratory services. You say that you disagree with the denial. The Plan denied your request. The Plan says that this is not covered.
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. We looked at the file and Medicare rules. This test is currently listed as not covered by Medicare in the DEX Diagnostic Exchange. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (81599) provided to the enrollee on October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with an out of network provider.
You asked the Plan to pre-approve an Intracept procedure out of network You say that the services are medically necessary. The Plan denied your request. The Plan stated that there are providers in network who can render this service. Maximus upheld the Plans decision. You appealed to the ALJ. The ALJ remanded the case back to Maximus stating the incorrect Plan contract was reviewed. Maximus requested the correct 2023 Plan contract from the Plan and the case was reopened.
Our decision remains unchanged. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the use of an out of network provider. Therefore, we decided that the Plan does not have to pre-approve services with an out of network provider.
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 this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
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 enrollee is scheduled/approved for a posterior L4-S1 laminectomy. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, hand; minimum of 3 views (X-ray) provided to the enrollee on September 29, 2022.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that Medicare rules for payment of this claim have not been met.
Maximus overturned the Plan's denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 22, On Campus-Outpatient Hospital. A review of the documentation shows these services were performed while the enrollee was inpatient in the hospital. 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 cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, hand; minimum of 3 views (X-ray) provided to the enrollee on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491 and 87640 billed for date of service 
March 12, 2023. 
 
You asked the Plan to pay for procedure codes 87491 and 87640. You say that these services were necessary 
and were reported appropriately. The Plan denied your request. The Plan says these services are not supported 
for separate payment. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 codes 87491 and 87640. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found that CPT 87491 is a test for 
Chlamydia trachomatis using amplified probe technique. However, the provided records in this case do not 
document this test. In addition, the records document one urine specimen on one date at one point in time was 
tested with no evidence that CPT 87640 was separate and distinct from CPT 87641. 
 
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 codes 87491 and 87640 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87491 and 87640 billed for date of service March 12, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment code E0675 billed for date of 
service November 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation proves medical necessity. 
The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E0675 was billed for the treatment of a unilateral inguinal hernia. Claims billed with 
code E0675 are considered not reasonable and necessary. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for durable medical equipment code E0675 billed for date of service November 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to approve coverage for Korsuva separately as its coverage is already included in the approval of the ESRD service.
You asked the Plan to provide coverage for Korsuva. You say that this drug is medically necessary. The Plan denied your request. The Plan says this is not a valid request for coverage. Maximus overturned the Plan's denial for medical necessity. The Plan requested a reopen and explained the drug itself was not denied and that the provider needed education on how drugs administered during dialysis treatment are requested and billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must request services correctly.
In this case, the Plan did not deny coverage for the drug. The Plan denied its request for separate approval and ultimately separate payment as the cost of the drug is considered a supply used during the dialysis treatment. Therefore, we decided that the Plan does not have to provide separate approval for Korsuva.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy-duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303x13 months). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that you are requesting reconsideration 
because the bed the enrollee currently has is broken and she needs a new bed. The Plan denied your request. 
The Plan says the records show the enrollee weighs less than 350 pounds. The request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the enrollee meets one of the criteria for a fixed height hospital bed and the enrollee's 
weight is more than 350 pounds but does not exceed 600 pounds.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of a heavy-duty hospital bed have not been met. Specifically, the records 
show that the enrollee's weight is less than 350 pounds, therefore, the enrollee does not meet criteria for a 
heavy-duty hospital bed. Therefore, we decided that the Plan does not have to pre-approve a hospital bed, 
heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, 
with any type of side rails, with mattress (E0303x13 months).