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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (62323), fluoroscopic 
guidance and localization of needle (77003), and anesthesia for diagnostic or therapeutic nerve blocks and 
injections (01992). 
 
You asked the Plan to pre-approve the outpatient 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 follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for three months. 
 
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 outpatient services. Our reviewer 
says that the outpatient services are not medically necessary. Our physician reviewer found the provided documentation does not support that the enrollee had at least 50% pain relief for 3 months. The reviewer also 
found that anesthesia administered sedation is not indicated for an ESI absent a specific reason such as morbid 
obesity, psychiatric illness or unstable medical condition. Therefore, the reviewer found that the requested 
services are not medically reasonable or necessary. 
 
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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural steroid injection (ESI) (62323), fluoroscopic guidance and 
localization of needle (77003), and anesthesia for diagnostic or therapeutic nerve blocks and injections (01992).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 5, 2022, to 
March 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 5, 2022, to 
March 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 18, 2022, 
to March 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 18, 2022, to 
March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 14, 2022, to 
February 12, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 14, 2022. The NOA was not received by the Plan until December 
15, 2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from January 14, 2022, to February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97597 and 97598 provided on April 27, 
2022. 
 
You asked the Plan to pay for procedure codes 97597 and 97598. You say that the medical records support the 
billing of codes 97597 and 97598. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 97597 and 97598. 
 
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 97597 is Debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) 
surface area; first 20 sq cm or less. The definition of code 97598 is Debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary 
procedure). 
 
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 97597 and 97598. Our reviewer says that 
the medical records do not support the billing of codes 97597 and 97598. Our reviewer found the note 
describes cleaning and dressing the wounds. The note does not mention debridement of any of the wounds that 
were addressed. 
 
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 97597 and 97598 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 97597 and 97598 provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism, electric (E0627) and a 
miscellaneous DME supply, accessory, and/or service component (A9900). 
 
You asked the Plan to pre-approve a seat lift and a miscellaneous DME accessory. You say that you frequently 
suffer from gout which cause your foot and knee to swell, and you use a knee brace and bandages for 
pain/support. The Plan denied your request. The Plan says you do not meet criteria for approval of the 
requested item. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
 
 
 
 We looked at the file and Medicare rules. The records show that you can safely sit and stand from various 
surfaces in your home. You do not need help from others to sit and stand. We do not have evidence that the lift 
chair is medically necessary. The LCD confirms that the seat lift is covered if all of the conditions listed in the 
Medicare rules section are met. You do not meet all of the conditions required for the requested lift. Based on 
this information, we decided that Medicare rules for coverage of a seat lift and a miscellaneous DME accessory 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism, 
electric (E0627) and a miscellaneous DME supply, accessory, and/or service component (A9900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased online on August 21, 2022. 
 
You asked the Plan to pay for the walker. You say that the walker was approved but the medical supply 
company didn't have one available.  You said that you purchased this walker online and were able to get it for a 
lower price. The Plan denied your request. The Plan says you purchased this item from a non-Medicare 
certified provider, so it is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
walker you purchased online on August 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acrylic socket (L5631). 
 
You asked the Plan to pre-approve an acrylic socket. 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 follows Medicare rules. Medicare rules say that lower limb prosthesis are covered when certain 
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 an acrylic socket. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found per Local Coverage Determination 
 lower limb prosthesis L33787 when an above knee initial prosthesis (L5590) prosthesis is provided, 
prosthetic substitution and/or additions of procedures and components are covered in accordance with the 
functional level assessment except for codes which include L5631. Under Medicare guidelines the L5631 is not medically necessary. 
 
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 acrylic socket have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an acrylic socket (L5631).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve a SI joint injection. 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 a SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, there is no documentation on physical examination of three (3) or more 
positive tests results. The clinical value and effectiveness of an SI joint injection in the absence of tenderness 
and negative provocative testing results have not been demonstrated in the peer-reviewed literature. The review 
has determined that the service at issue is not medically reasonable or necessary. 
 
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 SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71045 is bundled into payment for code 74022.  
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 71045 
is a column II code to column I code 74022. 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 71045 billed for date of service August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for COVID-19 vaccine administration provided October 28, 2021.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says at the time of administration, costs for these services for MA Plan participants were to be submitted directly to Original Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information regarding the regulations.
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 should have been submitted directly to Original Medicare. Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine administration provided October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hernia repair provided to the enrollee on March 7, 2022.
You asked the Plan to pay for the initial hernia repair. You say that you are resubmitting the claim with medical
records and the claim should be reviewed for payment. The Plan denied your request. The Plan says that
procedure code 49505 has an MUE value of 1 but 2 units were billed. Maximus overturned the Plans denial
stating the medical records support the services billed. The Plan requested a reopen and stated the issue was
with the modifier billed on the claim.
The Plan explained that this claim denied because this service was inappropriately billed. This service was not
billed with the appropriate modifier. The Plan states the provider needed to bill this service with Modifier 50 -
to indicate a bilateral surgical procedure. The modifier provides a means for reporting a bilateral surgical
procedure while still identifying the procedure began on the left side.
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 codes and when necessary, the
appropriate modifiers.
The Plan did not deny payment based on the service provided but on how the service was billed. The claim in
the file shows the omission of the appropriate modifier. 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 the initial hernia repair provided to
the enrollee on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pay for inpatient hospital services provided on July 12, 2021, to July 16, 2021 code 871.
You asked the Plan to pay for the inpatient hospital services originally billed. You say that this claim should be paid as billed. The Plan denied your request. The Plan says that the Medicare billing criteria were not met. Maximus overturned the Plans denial for no medical records in the file. The Plan requested a reopen and provided the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is the DRG downgrade from 871 (Septicemia or severe sepsis w/o mechanical ventilation greater than 96 hours with MCC) to 194 (Simple pneumonia and pleurisy with complication or comorbidity) for the dates of service July 12, 2021, through July 16, 2021. The medical records show the enrollee was a then 37-year-old woman with a medical history that included asthma, chronic hypoxic respiratory failure, diabetes, hypertension, schizophrenia, and morbid obesity. She presented to the hospital on July 12, 2021, with cough and shortness of breath. In the Emergency Department, the enrollee was ill-appearing and in acute distress with respiratory symptoms. She was fully oriented. It was documented that the enrollee was markedly tachycardic, tachypneic, febrile, and hypoxic. Laboratory studies were notable for marked leukocytosis and hyperglycemia, and elevations of creatinine, arterial lactate, lactic acid, procalcitonin, and "ProBNP". Chest imaging was notable for extensive bilateral infiltrates. The enrollee was placed on BiPAP with 100% oxygen. IV fluid, 30 cc/kg, was administered. The enrollee was diagnosed with acute-on-chronic hypoxic respiratory failure and sepsis due to pneumonia. Broad spectrum antibiotics were administered. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis is an overwhelming and life-threatening inflammatory response to infection that can lead to tissue damage, organ failure and death.
The clinical documentation supports that DRG 871 is appropriate in this case, as the diagnosis of sepsis, unspecified organism (A41.9) is supported by the clinical documentation in the medical record. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on July 12, 2021, to July 16, 2021 originally billed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) visit provided to the enrollee on October 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the PT visit. You say that you faxed the referral from the enrollee's primary care physician. The Plan denied your request. The Plan says that the referring physician was not the enrollee's primary care physician on file and not a network provider.
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. The Plan has indicated the referring provider was not a network provider or the enrollee's primary care physician at the time of referral. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) visit provided to the enrollee on October 21, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) (93010) provided on March 29, 2022.
You asked the Plan to pay for the EKG. You say that the claim should be paid. The Plan denied your request.
The Plan says this claim is a duplicate of a previously paid claim and was correctly denied.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were
reimbursed by the Plan on April 14, 2022. Comparison of the two claims shows these are exact duplicates.
There is no evidence presented to support that the billed items/services were provided twice on the same date.
Based on this information, we decided that the Medicare rules for the EKG have not been met. Therefore, we
decided that the Plan does not have to pay for the electrocardiogram (EKG) (93010) provided on March 29, 2022.