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

 
We decided that the Plan does not have to pre-approve an allograft and/or autograft (INFUSE) (20930, 20936). 
 
You asked the Plan to pre-approve an allograft and/or autograft (INFUSE). You say that this is medically 
necessary. The Plan denied your request. The Plan says the requested service is experimental, investigational, 
and unproven. 
 
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 an allograft and/or autograft (INFUSE). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further 
studies are needed to corroborate that the requested allograft would be as safe or better than standard autograft 
procedures. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 allograft and/or autograft (INFUSE) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an allograft and/or autograft (INFUSE) (20930, 20936).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) for the lower left quadrant, the 
lower right quadrant, the upper left quadrant, and the upper right quadrant, and periodontal maintenance 
(D4910) provided from February 8, 2023, to May 11, 2023. 
 
You asked the Plan to pay for gingival irrigation (D4921) for the lower left quadrant, the lower right quadrant, 
the upper left quadrant, and the upper right quadrant, and periodontal maintenance (D4910). You say that you 
were informed that you were indeed insured, and your benefits were active. The Plan denied your request. The 
Plan says this service is not covered by your dental plan. 
 
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 gingival 
irrigation (D4921) for the lower left quadrant, the lower right quadrant, the upper left quadrant, and the upper 
right quadrant, and periodontal maintenance (D4910) provided from February 8, 2023, to May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87652, 87899, and 87900 for date of service 
December 8, 2022. 
 
You asked the Plan to pay for procedure codes 87652, 87899, and 87900. 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. 
 
We find that CPT code 87652, 87899, and 87900 is not supported in the medical record. Specifically, the 
documentation did not include a quantification for the result; therefore, code 87652 cannot be verified. 
The medical records do not document direct optical observation; therefore, code 87899 cannot be verified. 
The medical records do not show quantitative infectious agent drug susceptibility completed; therefore, code 
87900 cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 87652, 87899, and 87900 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 87652, 87899, and 87900 for date of service December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional acupuncture visits. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary.  
The Plan denied your request. The Plan says the requested services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case. 
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that the enrollee has chronic 
low back pain that radiates to her buttocks and leg. Magnetic resonance imaging (MRI) shows that the enrollee 
has vertebral compression fractures and multi-level degenerative disc disease. She received 5 sessions of 
acupuncture but there is no documentation of the degree and duration of the pain relief. There is no description 
provided of the functional improvement attained after 5 sessions. Due to a lack of documentation of 
improvement, this request is deemed not medically reasonable and necessary.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3 additional acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transluminal balloon angioplasty (36907), transcatheter 
placement of intravascular stent(s) (36908), introduction of needle(s) and/or catheter(s), dialysis circuit (36902, 
36903), and dialysis circuit permanent vascular embolization or occlusion (36909). 
 
You asked the Plan to pre-approve transluminal balloon angioplasty, transcatheter placement of intravascular 
stent(s), introduction of needle(s) and/or catheter(s), dialysis circuit, and dialysis circuit permanent vascular 
embolization or occlusion. 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. 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 36901 is a column II code to column I codes 36902 and 36903. This 
claim has not been billed with an appropriate modifier to bypass the edit. 
 
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 pre-approve transluminal balloon angioplasty, transcatheter 
placement of intravascular stent(s). Our reviewer says that the services are not appropriate. Our reviewer found 
documentation does not support why these 3 separate codes are being coded separately, so the services as 
coded separately are not medically appropriate.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transluminal balloon angioplasty, transcatheter placement of intravascular 
stent(s), introduction of needle(s) and/or catheter(s), dialysis circuit, and dialysis circuit permanent vascular 
embolization or occlusion have not been met. Therefore, we decided that the Plan does not have to pre-approve 
transluminal balloon angioplasty (36907), transcatheter placement of intravascular stent(s) (36908), 
introduction of needle(s) and/or catheter(s), dialysis circuit (36902, 36903), and dialysis circuit permanent 
vascular embolization or occlusion (36909).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 20, 2022, to March 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $100 
copayment per day, days 1-4, for each medically necessary covered inpatient stay. 
 
You have been asked to pay a $400 copayment for the inpatient hospital stay ($100 copayment x 4 days = 
$400). This item/service falls within the inpatient hospital care 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 inpatient hospital stay provided from March 20, 2022, to March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retractable or removable mounting hardware for 
joystick (E1028), electronic connection between wheelchair controller (E2310), and accent color (K0108). 
 
You asked the Plan to pre-approve a retractable or removable mounting hardware for joystick, electronic 
connection, and accent color. You say that you have severe balance issues and fall often when you are walking. 
You also say that you need a power chair. The Plan denied your request. The Plan says code K0108 is meant to 
represent the accent color of the wheelchair, and is not a covered service. The Plan says the documentation 
does not show that you have difficulty with transfer, especially as you are able to walk with two canes at times, 
and thus have no documented need for a swing away joystick. The Plan also says that the documentation does 
not show that you are unable to operate a single switch. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that if a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. The rules also say that for equipment to be covered, it must 
primarily serve a medical purpose. 
 
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 retractable or removable mounting 
hardware for joystick. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have cerebral palsy and impaired 
ambulation. You do walk short distances and can stand. Our reviewer found that you do not use a sliding board 
transfer, and the swingway joystick is not medically necessary. Our physician reviewer also found that you 
have adequate upper body strength to manage standard power drives. 
 
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 retractable or removable mounting hardware for joystick, electronic 
connection, and accent color have not been met. Specifically, the accent color does not serve a purpose that is 
primarily medical in nature. This item is available to the public and would be helpful even to those who are not 
sick or injured. Therefore, we decided that the Plan does not have to pre-approve a retractable or removable 
mounting hardware for joystick (E1028), electronic connection between wheelchair controller (E2310), and 
accent color (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 22, 2022, to October 23, 2022.
You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were emergent and it was appropriate to take the enrollee to the nearest hospital for immediate care. The Plan denied your request. The Plan says that your care could have been provided at an observation level of care.
Our Medical Director looked at the case file and the reopen request. At issue is payment for acute inpatient hospital care. Our Medical Director states that the medical records do not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.
Given the resolution of your symptoms, the normal neurological exam, and normal imaging, the documentation does not support that it was reasonable for the admitting physician to expect that the necessary hospital care (including earlier emergency department and/or observation care) would span two midnights in this case. Our Medical Director found that your condition does not meet criteria for coverage for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 22, 2022, to October 23, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services coded as 87150-59,87481-59,87798-59,87801-59,87640-59, and 87653-59, provided to the enrollee on December 16, 2022.
You asked the Plan to pay for this claim as billed. You say that this testing should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and noted that there is no applicable Medicare Local Coverage Article or Local Coverage Determination for this provider and/or the enrollees geographic area. The Medicare guidance for coding states a test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components although the test reports multiple individual pathogens and/or targets. Medicare's expectation is that stacking of codes in unacceptable.
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, based on the test panel provided to the enrollee, this claim should be reported with one code and cannot be unbundled for separate payment.
Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for lab services coded as 87150-59,87481-59,87798-59,87801-59,87640-59, and 87653-59, provided to the enrollee on December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 7, 2022.  
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
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. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
November 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for diagnostic testing provided on August 8, 2022.
 
You asked the Plan to pay for the diagnostic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says that the member's plan covers necessary services and supplies to treat a disease or injury. To meet this requirement the service or supply must be accepted under recognized professional standards as appropriate and effective for the diagnosis, care or treatment. It should not be experimental or still under clinical investigation. This expense does not meet this requirement of the member's plan of benefits based on the information given.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding rule to substantiate their denial. Therefore, we decided that the Plan has to pay for diagnostic testing provided on August 8, 2022.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L3 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary because records show that this L3 compression 
fracture is more than 12 weeks old. Additionally, the enrollee has fragment retropulsion from this L3 
compression fracture. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L3 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding the L3 compression fracture being acute or subacute. The March 2, 2023, radiographs noted 
the L3 compression fracture. Moreover, there is magnetic resonance imaging corroboration of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3 kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87652, 87900, 87899, and 13 units of 
87798-91 billed for date of service October 10, 2022. 
 
You asked the Plan to pay for procedure codes 87652, 87900, 87899, and 13 units of 87798-91. You say that 
these services were reported appropriately and are supported in the medical record. The Plan denied your 
request. The Plan says these codes are not supported in the medical record. 
 
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 procedure codes 87652, 87900, 87899, and 13 units of 
87798-91. Our reviewer says that these services are not supported in the medical record. Our reviewer found 
that the laboratory report does not include documentation of quantification (87652), quantitative prediction of 
drug susceptibility phenotype (87900) or direct optical observation (87899) as required by these codes. In 
addition, the laboratory report does not include documentation to support that the laboratory tests described by 
87798 were repeated, and therefore the use of modifier 91 for 13 units of 87798 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 procedure codes 87652, 87900, 87899, and 13 units of 87798-91 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87652, 87900, 87899, and 
13 units of 87798-91 billed for date of service October 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) of the neck for the enrollee.
You asked the Plan to pre-approve a CT of the neck. You say that this service is necessary for you to rule out metastasis cancer. The Plan denied your request. The Plan says that these services are not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a CT of the neck. Our Medical Director states that the documentation does not support that a CT scan of the neck was medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a CT of the neck.
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 CT of the neck have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) of the neck for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 73030 provided to the enrollee on August 23, 2022.
You asked the Plan to pay for procedure code 73030. You say that there is no modifier required. The Plan denied your request. The Plan says that this code is included in the skilled nursing facility payment and is not separately payable. Maximus overturned the Plan's denial because of a lack of documentation. The Plan requested a reopening and provided documentation to confirm the enrollee was in the SNF when these services were provided. The Plan is correct in this case as Medicare rules say that carriers may not pay for the technical component of radiology services furnished to SNF inpatients during a Part A covered stay. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 73030 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 73030 provided to the enrollee on August 23, 2022.