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

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies provided on May 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the documentation did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation 
(TENS) supplies provided on May 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Methotrexate tablet. 
 
You asked the Plan to pre-approve Methotrexate. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not, as prescribed, among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Methotrexate tablet.  
 Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 99140. The Plan denied your request. The Plan says procedure 
code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient evaluation provided to the enrollee on July 3, 
2022. 
 
You asked the Plan to pay for the services. You say that this is the first time that the enrollee has seen this 
provider under this Tax ID. The Plan denied your request. The Plan says other professional claims have been 
previously processed within the past three years. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter." 
 We find that CPT code 99205 is not supported in the medical record. Specifically, it is not appropriate to bill a 
new patient code in this case, as a new patient code was billed within the past three years. 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 a new patient evaluation provided to the enrollee on July 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to receive rehab at this facility. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation therapy. Medically necessary care can be provided in a different level of 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77080 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 77080. You say that this should e paid for. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 77080 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 77080 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77080 billed for date of service June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device, four or more leads, for multiple nerve stimulation (E0730) provided June 2, 2022. 
 
You asked the Plan to pay for the TENS device. You say that please review the claim denial for accuracy. The 
Plan denied your request. The Plan says Transcutaneous Electric Nerve Stimulation (TENS) units and garments 
and supplies for chronic back pain are not a Medicare covered benefit. 
 
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 pay for the TENS device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the NCD specifically excludes TENS for back pain unless the patient is enrolled in a clinical 
trial. This enrollee is not enrolled in a clinical trial and therefore, the request is deemed 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 TENS device have not been met. Therefore, we decided that the Plan does 
not have to pay for the transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for 
multiple nerve stimulation (E0730) provided June 2, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for emergency room services provided from July 20, 
2022, to July 22,2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that the enrollee should not 
be responsible to pay this because they were admitted to the hospital as an inpatient. The Plan denied your 
request. The Plan says that 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). The enrollees contract with the Plan says that enrollees must pay 
$50 for emergency services. The enrollees contract with the Plan also says that enrollees do not pay the 
emergency room visit cost share if they are admitted to the hospital within 24 hours for the same condition. 
 
The Plan says the enrollee must pay a $50 copayment for emergency room services. Medical records submitted 
by the Plan indicate the enrollee was admitted as an inpatient. Based on the plan contract, however, the enrollee 
cannot be asked to pay more than $0 for inpatient services. Therefore, we decided that the Plan has to waive the 
copayment for emergency room services provided from July 20, 2022, to July 22,2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the thorax (71250). 
 
You asked the Plan to pre-approve a CT of the thorax. You say that you feel this scan is necessary because it 
was ordered by your doctor. The Plan denied your request. The Plan says the medical policy criteria are not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT of the thorax. Our reviewer says 
that a CT of the thorax is not reasonable and necessary. Our physician reviewer found the CT report from April 
19, 2021, described stable bilateral pulmonary nodules and a recommendation for follow-up every 2 years, for 
a total 5 years, to comply with Fleischner Society guidelines. Our reviewer also found that the ground glass 
appearance of the 10-millimeter nodule provides a valid reason for surveillance and the need for a follow-up 2 
year scan after the April 19, 2021, exam is appropriate, but the next follow-up scan would be due in April, 
2023, and not at the current time. 
 
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 thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the thorax (71250).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on May 25, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the testing 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 pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 74-year-old male who is being prescribed oxycodone and gabapentin for chronic 
pain. Definitive drug testing was performed. However, the provided documentation did not clearly show a prior 
urine drug screening result that was unexpected or suspicious that would justify follow-up with a 
comprehensive and definitive drug testing panel that includes many drug classes not applicable to this case. The testing appears to be excessive and, therefore, this request for definitive drug testing will be considered 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88361, 88312, 88305 and 88112 billed for 
date of service February 18, 2022. 
 
You asked the Plan to pay for procedure codes 88361, 88312, 88305 and 88112. You say that these services 
were necessary and are supported as billed. The Plan denied your request. The Plan says these services were 
not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88361, 88312, 88305 and 88112 are physician pathology services which have 
both professional components (PC) and technical components. These services were not billed with modifier 26 
to indicate that only the professional component payment is requested. This means that payment is requested 
for both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88361, 88312, 88305 and 88112 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88361, 88312, 88305 and 88112 billed for date of service February 18, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 1, 
2022 to April 30, 2022. 
 You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no 
longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 1, 2022 to April 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63012, 76000, and 63057, billed for date of 
service January 31, 2022. 
 
You asked the Plan to pay for procedure codes 63012, 76000, and 63057. The Plan denied your request. The 
Plan says payment for these codes is bundled into payment for other billed codes.  
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 codes 
63012 and 76000 are column II code to column I code 22633. We have also confirmed that code 63057 is a 
column II code to column I code 22634. 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 codes 63012, 76000, and 63057, billed for date of service January 
31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 17, 2022, to 
May 5, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's 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 April 17, 2022. An NOA was not submitted to the Plan. 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 provided from April 17, 
2022, to May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from April 8, 2022, to 
April 13, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you cannot afford to pay for these services. 
The Plan denied your request. The Plan says Medicare does not pay for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from April 8, 2022, to April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported as 
billed. 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 January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair and accessories (codes K0856, E2361, E1002, and E2607) for the enrollee.
You asked the Plan to pre-approve the requested accessories. You say that at the time of the appeal, the requested accessories ere medically 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 is correct in the case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for the requested power wheelchair and accessories. Review of the medical records confirm as the Plan states, the enrollee does not have a neurological condition that meets the criteria required for approval of the requested power wheelchair and accessories. Medicare rules for coverage of the requested equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair and accessories (codes K0856, E2361, E1002, and E2607) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has tried compression stockings and 
leg elevation, which failed. The Plan denied your request. The Plan says this 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not meet the general criteria for varicose vein surgery and does not meet the 
more specific criteria for endovenous ablation. The documentation confirms that the patient has severe 
peripheral artery disease. It is not sufficiently documented that the patients proximal great saphenous vein 
reflux is contributing to his foot lesions or leg pain. The criteria require that the patients symptoms be 
attributable to the vein planned for treatment. Additionally specific criteria require that there be an absence of 
significant peripheral artery disease. This is not the case. Endovascular intervention does not confer a 
designation of absence of peripheral artery disease. Endovascular treatments are often not durable, and the 
elimination of the patients saphenous vein could deny the patient limb salvage options in the foreseeable 
future. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy.