Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes Q4262, 15275, and 15276 billed for date of service 
May 24, 2023. 
 
You asked the Plan to pay for the billed services. You say that the care was medically necessary. The Plan 
denied your request. The Plan says that the billed codes are not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied services as the records do not indicate the name of the 
servicing provider. However, the medical records submitted are signed by the provider at issue. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for procedure codes Q4262, 15275, and 
15276 billed for date of service May 24, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
first 2 vertebral bodies (64628). 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only modic changes without facet degenerative joint disease (DJD) or stenosis. The cause of pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve, first 2 vertebral bodies (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00731 billed for date of service August 14, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed service is 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. 
 
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 pay for the billed service. Our reviewer found that 
the enrollee has a history of chronic kidney disease, diabetes, who had endoscopy with monitored anesthesia 
care. Documentation does not detail why procedure could not be performed with moderate sedation or why 
monitored anesthesia care was medically necessary. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 00731 billed for date of service August 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on August 28, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on August 
28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36415) provided on March 1, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 36415 is "Collection of venous blood by venipuncture". 
 
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 the services. Our reviewer says that the use of code 36415 is 
not supported by the records provided. Our reviewer found that the documentation does not describe a blood 
draw. Although there is an order for it, it cannot be verified that venipuncture was performed. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (36415) provided on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87086 and 81001 for date of service January 3, 2022. 
 
You asked the Plan to pay for codes 87086 and 81001. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for codes 87086 and 81001 was not filed until August 9, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for codes 87086 and 81001 for date of service January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound care supplies provided on April 
05, 2023. 
 
You asked the Plan to waive the coinsurance for the wound care supplies. You say that the cost share is wrong. 
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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for the wound care supplies. This item/service falls within the 
durable medical equipment (DME) 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 coinsurance for 
the wound care supplies provided on April 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi precision attachment (D6192) for teeth #22 and 
#27. 
 
You asked the Plan to pre-approve D6192. You say that this dental work is medically necessary. The Plan 
denied your request. The Plan says the denied dental service 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 pre-approve a 
semi precision attachment (D6192) for teeth #22 and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a K3 hydraulics knee for the enrollee.

You asked the Plan to provide coverage for a K3 hydraulics knee. You say that at the time of the appeal, a K3
hydraulics knee was necessary. 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 stated that Maximus did not apply the correct criteria. The Plan noted that the
medical records do not document a need for any K3 components. The medical records do not show why a K2
foot and K2 knee cannot be used for the enrollee's prosthesis. The requested microprocessor knee (Freedom
Quattro) exceeds the enrollee's need and is not reasonable and necessary per Medicare criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare does not provide coverage for prosthetic components that exceed
and enrollee's needs. 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 a K3 hydraulics
knee have been met. Therefore, we decided that the Plan does not have to provide coverage for a K3 hydraulics
knee for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit for allergen immunotherapy services provided
on January 13, 2023.

You asked the Plan to pay for these services. You say that the services this physician is providing is lifesaving,
and you cannot go without these services. The Plan denied your request. The Plan says that this service cannot
be paid for because the provider has opted out of Medicare. Maximus overturned the Plan's denial because of a
lack of information. The Plan requested a reopening and states that the provider is not enrollee in Medicare.
The Plan is correct in this case. The rules say that no Medicare payment may be made to a beneficiary for items
or services provided directly by a physician or practitioner who has opted out of the program except in cases
involving emergencies or urgently needed care. The services at issue in this appeal were provided in a nonurgent,
non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we
decided that the Plan does not have to pay for the office visit for allergen immunotherapy services provided on
January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308-25 rendered on July 15, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records describe that the 
enrollee was seen, and wound care was provided for multiple wounds. In this case, the documentation does not 
include a significant, separately identifiable evaluation and management service above and beyond the wound 
care performed. Therefore, CPT 99308 and the modifier 25 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99308-25 rendered on July 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on July 13, 2023. 
 
You asked the Plan to pay for cataract surgery. You say that the service was medically necessary 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 cataract surgery 
provided on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on July 10, 2023. 
 
You asked the Plan to pay for a new patient office visit. You say that the provider was unaware that they were 
out-of-network. 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 a new patient office visit 
provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft of the
mandible or maxilla (D7950) provided on December 8, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that it was recommended that you get the surgery done.
The Plan denied your request. The Plan says that this was not a covered service and approval was not
requested. Maximus overturned the Plan's denial. The Plan requested a reopening.

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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft of
the mandible or maxilla (D7950) provided on December 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on August 
24, 2023. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $50 
copayment for Physician/Practitioner services/specialist. 
 
You have been asked to pay a $50 copayment for specialist office visit. This item/service falls within the 
Physician/Practitioner services/specialist 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 specialist office visit provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service August 9, 
2023. 
 
You asked the Plan to pay for procedure code A4557. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code A4557 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4557 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4557 billed for date of service August 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 22, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that medical records were provided. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a respiratory pathogen panel was provided. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. Code 87640 was billed with a -59 modifier. The records do not 
show that code 87640 was separate and distinct from the panel test provided. 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 87640 billed for date of service August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (97032) provided on August 2, 
2023. 
 
You asked the Plan to pay for the electrical stimulation (97032). You say that you are not out-of-network and 
would like the Plan to reconsider payment. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation (97032) provided on August 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspiration for bone grafting.  
 
You asked the Plan to pre-approve the bone marrow aspiration for bone grafting. You say that the enrollee 
needs the surgery because they are in a lot of pain and their quality of life is at stake. The Plan denied your 
request. The Plan says the bone marrow aspiration for bone grafting is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspiration. Our 
reviewer says that the bone marrow aspiration for bone grafting is not medically necessary. Our physician 
reviewer found that bone marrow aspirate is considered experimental when used as bone graft material in spine 
surgery. 
 
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 bone marrow aspiration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspiration for bone grafting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a microprocessor knee (L5828, L5845, L5848,
L5856) for a lower limb prosthesis.

You asked the Plan to provide coverage for a microprocessor knee (L5828, L5845, L5848, L5856) for a lower
limb prosthesis. The Plan denied your request. The Plan says the Medicare criteria for the microprocessor knee
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct coverage criteria. The Plan notes that the enrollee was just approved for a manual
wheelchair. The Plan states the enrollee will require the use of wheelchair on a regular basis in the home. The
Plan further notes the documentation from the enrollee's physician initially states that enrollee is a K2
ambulator. Medicare criteria for a microprocessor knee are not met.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, the
medical records provided do not support that the enrollee qualifies for a microprocessor knee and is not a K3
ambulator. Therefore, we decided that the Plan does not have to provide coverage for a microprocessor knee
(L5828, L5845, L5848, L5856) for a lower limb prosthesis.