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

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve epidural injections. You say that the injections are medically necessary 
because you need the injection in order to improve your condition.  The Plan denied your request. The Plan 
says you do not meet the criteria for approval for this procedure. 
 
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 epidural injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found physical therapy and a lumbar support brace were ordered, but it is not clear whether 
the therapy has been delivered. You take Gabapentin, cyclobenzaprine and tramadol for pain. The MRI shows a 
prior hemilaminectomy as well as multiple disc bulges. with foraminal stenosis. There is a lack of 
documentation of the failure of conservative therapy. Therefore, at this point, the request is denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service coded 
99443 provided on 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
In this case, the CPT Code Manual definition of code 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion.  
We find that CPT code 99443 is not supported in the medical record. Specifically, code 99214 was billed on 
the history claim. If the telephone service ends with a decision to see the patient within 24 hours or next 
available urgent visit appointment, the code is not reported; rather the encounter is considered part of the pre-
service work of the subsequent evaluation and management (E/M) service, procedure, and visit. Likewise, if 
the telephone call refers to an E/M service performed and reported by that individual within the previous seven 
days (either requested or unsolicited patient follow-up) or within the postoperative period of the previously 
completed procedure, then the service(s) is considered part of that previous E/M service or procedure. Based on 
this information, we decided that Medicare rules for coverage of the telephone evaluation and management 
service have not been met. Therefore, we decided that the Plan does not have to pay for the telephone 
evaluation and management service coded 99443 provided on
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee can continue to be safely managed in 
the current care setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with septic shock related to 
multiple sources of infection including an infected G-tube site and complicated by acute respiratory failure. She 
was treated with antibiotics, fluids, mechanical ventilation, trach placement, PEG placement, and wound care 
for chronic abdominal wound. Recent notes describe the patient as now tolerating trach collar weaning but 
requiring ongoing wound care and additional weaning. The patient appears to be more stable and improving 
and should only require short-term additional acute care services that can safely be provided at the current 
facility until more appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient 
requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is recommended.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing billed for date of service 
November 9, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the bode 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. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that the 
testing of 22 or more drug classes were ordered or provided. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the definitive drug testing billed for date of service November 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Botox injection (CPT code J0585). 
 
You asked the Plan to pre-approve the Botox injection. You say that the injection will allow relaxation to the 
enrollee's rectus muscles to allow for closure of their abdominal wall secondary to loss of domain. The Plan 
denied your request. The Plan says this medication is not shown to be medically necessary for your condition 
based on the clinical information that we have received. 
 
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 Botox injection. Our physician 
reviewer found the review has determined that the medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 Botox injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Botox injection (CPT code J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for miscellaneous durable medical equipment 
(E1399) unlisted special service, procedure or report (99199) extra wide, heavy duty commode chair (E0168) 
Bath/shower chair (E0240) toilet rail, each (E0243) and sales tax (S9999) purchased January 25, 2022 to March 
3, 2022. 
 
You asked the Plan to reimburse you for the durable medical equipment. You say that you are appealing the 
denial of reimbursement of the The Plan denied your request. The Plan says the equipment was purchased from 
providers who are not Medicare certified suppliers. 
 
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 reimburse you for miscellaneous durable 
medical equipment (E1399) unlisted special service, procedure or report (99199) extra wide, heavy duty 
commode chair (E0168) Bath/shower chair (E0240) toilet rail, each (E0243) and sales tax (S9999) purchased 
January 25, 2022 to March 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 4, 
2022, to March 28, 2022. 
 
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 provider did not bill as required by Medicare coding regulations. 
 
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 the denied home health services are not supported in the medical record. Specifically, this was 
submitted with the incorrect admit date of 8/6/21. 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 
home health services provided to the enrollee from March 4, 2022, to March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM device 
(K0553) provided February 11, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that attached you will find medical records that will 
show proof of medical necessity. The Plan denied your request. The Plan says services is not documented in 
the medical records. 
 
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 a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the delivery slip shows it was shipped on February 
1, 2022, and delivered on February 4, 2022. The date of service billed is February 9, 2022. The tracking 
numbers, the dates on the invoice/packing slip and the UPS delivery slip do not match. Additionally, the 
invoice/packing slip are for a different member. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
supply allowance used with a therapeutic CGM device (K0553) provided February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (49322) provided on October 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the 
primary procedure. 
 
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 use of code 49322 is 
not supported by the records provided. Our reviewer found that the operative report describes that while 
performing a cholecystectomy, a "Hydrops of the gallbladder" was found and sent for cultures. To cite the 
report: "...Laparoscope was inserted into the abdominal cavity... At wich point, using aspiration needle trocar, 
we aspirated the gallbladder and immediately noticed clear fluid that was aspirated, suggestive of hydrops of 
the gallbladder disease". In this case, the aspiration was performed during the primary procedure in same 
anatomical location. Therefore, this procedure would not be reported separately from the primary procedure, which in this case, is a surgical laparoscopy for cholecystectomy. 
 
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 (49322) provided on October 19, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from November 4, 2021, to 
November 24, 2021. 
 
You asked the Plan to pay for the home health services. You say that the Notice of Admission and claim were 
originally submitted timely and should be paid. The Plan denied your request. The Plan says that the claim was 
denied as it needs to be sent to a third party. The Plan was not able to review its denial at the appeal level due 
to missing the time frame. 
 
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. The Plan's claim denial rationale is that home health claims need to be sent to a 
third party. While Plans are permitted to use third parties for claims processing, it would be the Plan's 
responsibility to forward the claim to the third party if it were sent to the directly to the Plan in error. Maximus 
finds no other valid rationale for denial of payment for this claim. As such, we find that the denial is not 
substantiated. Therefore, we decided that the Plan has to pay for the home health services provided from 
November 4, 2021, to November 24, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (code A4595) billed for date of 
service August 4, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that code A4595 is an accepted code, 
and it should be paid. The Plan denied your request. The Plan says the proof of delivery was insufficient, and 
you did not provide records to verify an established relationship between the patient and the referring provider 
despite multiple requests. 
 
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 a valid proof of delivery in this case. Specifically, the packing slip that you 
provided and the USPS tracking information you provided are dated on April 4, 2022.  There is nothing on the 
USPS tracking/delivery information that connects the specific items listed on the packing slip with the date of 
service at issue in this appeal. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for electrical 
stimulator supplies (code A4595) billed for date of service August 4, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria for admission to an IRF 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 the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that he 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF. The enrollee can receive further services at a lower 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the next generation sequencing testing provided to the enrollee on December 30, 2021.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the testing is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the specimen was collected. We looked at the file and Medicare rules. The file indicates that the DOS of the testing is not the same as the date the specimen was collected. 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 next generation sequencing testing provided to the enrollee on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for laboratory services provided to the enrollee on August 2, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria are not met. Maximus overturned the Plans denial for insufficient information regarding the denial. The Plan requested a reopen and provided additional information. The Plan demonstrated that the documentation shows that the codes at issue were not billed with the -XU modifier. The Plan submitted proof to show the codes at issue were billed with the -XU modifier in error. The XU modifier is typically used to bypass column 1 column 2 code edits; however, the Medicare coding guidelines show there is no Procedure to-Procedure (PTP) edit to bypass for the codes billed.
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 if necessary, the appropriate modifiers. In this case, the -XU modifier was billed in error. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulation (PNS) device 
(64555). 
 
You asked the Plan to pre-approve a SPRINT PNS. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested device 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 a SPRINT PNS. Our reviewer says that 
the requested SPRINT PNS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found further studies are needed to corroborate this treatment is as good or better than standard 
treatments. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested SPRINT peripheral nerve 
stimulation (PNS) device 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 SPRINT PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a SPRINT peripheral nerve stimulation (PNS) device (64555).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99282 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 99282. The Plan denied your request. The Plan says payment for 
code 99282 is bundled into payment for code 99283. 
 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 99282 
is a column II code to column I code 99283. 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 99282 billed for date of service July 26, 2022.