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

We decided that the Plan does not have to pay for a walking boot (L4361) provided to the enrollee on May 24, 2022.
You asked the Plan to pay for these services. You say that the requested walking boot was medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial and stated that the records show this item was medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but that the claim was not submitted with the correct code. The provider inappropriately billed code L4361 with modifier GA which must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file, and modifier NU which is used to report new equipment. The Local Coverage Determination (LCD) L33686 - Ankle-Foot/Knee-Ankle-Foot Orthosis explains that claim lines billed without a KX modifier which indicates that the supplier has ensured coverage criteria for the DMEPOS billed is met and that documentation does exist will be rejected as missing information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, this claim could not be paid as billed due to the omission of a required modifier. Medicare rules for payment of this item are not met. Therefore, we decided that the Plan does not have to pay for a walking boot, code (L4361) provided to the enrollee on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99153 provided to the enrollee on June 24, 2022.
You asked the Plan to pay for procedure code 99153. You say that the medical records support that payment should be made for the denied services. The Plan denied your request. The Plan says that the code 99153 cannot be paid in a facility setting.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not payable to the physician for services provided in the facility setting. We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for procedure code 99153 provided to the enrollee on June 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on November 09, 2022. 
 
You asked the Plan to pay for x-ray services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for x-ray services provided 
on November 09, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 23, 2022, billed 
with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 
81345, 81272, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 
November 23, 2022, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, 81209, 81314, 81334, 81345, 81272, and 81479.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paclitaxel injections and bevacizuma-bvzr. 
 
You asked the Plan to pre-approve paclitaxel injections and bevacizuma-bvzr. You say that based on the 
enrollee's progression you believe that the services are medically necessary, studies show good response with 
this type of treatment. The Plan denied your request. The Plan says using these drugs might not help the type of 
cancer the enrollee has, and there is not clinical criteria to support this type of treatment. 
 
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 paclitaxel injection and bevacizuma-
bvzr. Our reviewer says that the drugs being requested are not medically necessary. Our physician reviewer 
found the requested use of paclitaxel injections and bevacizuma-bvzr are not FDA-approved for the enrollees 
diagnosis. The use of paclitaxel injection and bevacizuma-bvzr are not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The use of paclitaxel 
injection and bevacizuma-bvzr are not supported or not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paclitaxel injections and bevacizuma-bvzr have not been met. Therefore, we 
decided that the Plan does not have to pre-approve paclitaxel injections and bevacizuma-bvzr.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to hold you harmless for ambulance transport provided from urgent care to the emergency room on August 4, 2022, minus any applicable contractual copayment.
You asked the Plan to pay this transport. You say that you went to urgent care due to severe swelling. After you were given injections, the staff decided you should go to the emergency room, but you could not drive due to the injections given so an ambulance was called. You do not believe you should have to pay for this transport. The Plan denied your request. The Plan says that this claim could not be paid due to an incorrect diagnosis code listing on the claim by the provider. Maximus overturned the Plan's denial for insufficient explanation in the case file. The Plan requested a reopen and again stated this was a billing issue and a corrected claim would be reviewed.
The Plan must follow Medicare rules. Medicare rules state that Plans must provide clear contract language. The Plan contract says that when you have an emergency, you are to seek treatment right away. You went to urgent care, and you were ultimately transferred by ambulance to the emergency room at the direction of the urgent care staff. You were unable to drive due to the injections they had given you at urgent care. You would have no idea on who would respond for the transport nor how they would bill the transport. The Plan has not made it clear in the documentation in the case file that you would be held harmless for this billing other than your normal contractual copayment for ambulance transport. The Plan stated a correct claim would be reviewed if the diagnosis code error was corrected. You have not control over this. Therefore, it is our decision that the Plan is to hold you harmless for costs related to this transport, other than your normal contractual copayment for ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2301, E2311, E2313, E2377).
You asked the Plan to pre-approve the requested accessories. . You say that these accessories are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue for medical coverage are an electronic connection (E2311), expandable controller (E2377), and harness (E2313). Codes E2300 and E2301 are statutorily excluded. The enrollee was a then 39-year-old woman with a medical history that included spastic diplegic cerebral palsy and scoliosis that required spinal surgery. On February 4, 2022, the enrollee's upper extremity motor strength is documented to be -4 to 5/5. The Plan is correct in this case. The documentation 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. Rather, it appears that the enrollee's upper limb strength and function were adequate to be able to control the power options using their own switches. 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 requested accessories are not met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2301, E2311, E2313, and E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided from November 16, 
2022, to December 7, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says infrared therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided from November 16, 2022, to December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass cap on tooth #29 and # 31 (D6740) and 
fixed prosthodontic on tooth # 30 (D6245). 
 
You asked the Plan to pre-approve white glass cap and a fixed prosthodontic when meeting certain criteria . 
You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
prosthesis does not meet criteria. 
 
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. The Plan covers white glass 
cap and a fixed prosthodontic when the services are medically necessary and reasonable.  
 
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 white glass cap and a fixed prosthodontic. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
bridge as requested is not considered medically necessary as there has been no showing of an inability to wear 
a removable appliance.  The Plan does not allow for fixed bridgework generally but has a provision for those 
that have a documented inability to wear a removable partial denture due to neurologic or physical 
limitations.   As there was no documentation supplied that supports any disability being present, the Plan does 
not allow for reimbursement for a fixed bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of white glass cap and a fixed prosthodontic have not been met. Therefore, we 
decided that the Plan does not have to pre-approve white glass cap on tooth #29 and # 31 (D6740) and fixed 
prosthodontic on tooth # 30 (D6245).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 93971 billed for date of service July 20, 2022.
You asked the Plan to pay for procedure code 93971. You say that this service was medically necessary and is supported as billed. 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 93971 is 1. The MAI value for this code is 3. You billed 2 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 93971 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93971 billed for date of service July 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on February 08, 2023, to 
March 10, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on February 08, 2023, to March 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on January 
15, 2023. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you were transferred 
between facilities, and feel the facilities should cover this trip. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for the ambulance service. This item/service falls within the 
ambulance 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 the ambulance 
service provided on January 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you just had surgery and not doing well you need the 
additional assistance to make a full recovery. The Plan denied your request. The Plan says you don't meet all 
the requirements. Services needed may be provided safely in a lower level of care. 
 
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. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
January 12, 2023. 
 
You asked the Plan to pay for the dental service. You say that a representative told you to submit your full 
mouth x-ray and you would like the claim processed for payment. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 item or service was exhausted on the date of service of April 28, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367) provided on February 16, 
2023. 
 
You asked the Plan to pay for D0367. You say that you needed a dental implant for a badly damaged tooth. The 
Plan denied your request. The Plan says D0367 is not a covered benefit. 
 
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 cone 
beam CT capture (D0367) provided on February 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 60 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 60 routine transportation trips. You say that you need 
transportation to get to medical appointments. The Plan denied your request. The Plan says this request will 
exceed the maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 60 routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic - porcelain/ceramic (D6245) and core buildup, 
including any pins when required (D2950) provided on March 9, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D6245 and D2950. You say that you 
believed the services would be covered. 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 a pontic - 
porcelain/ceramic (D6245) and core buildup, including any pins when required (D2950) provided on March 9, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home modifications for a stair lift.  
 
You asked the Plan to pre-approve home modifications for a stair lift. You say that you cannot walk at all on 
your own and you have stairs in in your house. You also say that you cannot get up the stairs on your own, and 
your son has to carry you up and down the stairs all the time. The Plan denied your request. The Plan says your 
request is not a covered benefit because a stair lift is not primarily and customarily used to serve a medical 
purpose and is generally useful to a person in the absence of illness or injury. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve home modifications for a stair lift.