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

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on June 21, 
2021. 
 
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 Current Procedural Terminology (CPT) code 00865 AA (269 units) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 00865 is "Anesthesia for extraperitoneal procedures in 
lower abdomen, including urinary tract; radical prostatectomy (suprapubic, retropubic)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the primary code billed for anesthesia 
services was CPT 00865-AA, anesthesia for extraperitoneal procedures in lower abdomen, including urinary 
tract; radical prostatectomy (suprapubic, retropubic).  However, the anesthesiology intra-operative record to 
support the billed procedure was not submitted with the other medical records reviewed.  The CPT code 00865 appears to be the appropriate code for this surgical procedure, however, there is no documentation of the 
anesthesia record. In addition, the 269 units billed for this case does not seem to be accurate and should be 
reviewed and corrected. 
 
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 anesthesia services provided to the enrollee on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and cervical collar 
(L0174) provided March 23, 2021. 
 
You asked the Plan to pay for the orthoses. You say that please see attached medical documentation that meets 
all criteria to process the claim for payment. The Plan denied your request. The Plan says The services are not 
supported in the medical records received. 
 
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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of traumatic brain injury, bipolar disorder 
chronic pain, elevated liver enzymes, and hyperlipidemia. There is no specific clinical rationale for the 
requested lumbar-sacral orthosis (L0650) and cervical collar (L0174). 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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) and cervical collar (L0174) provided March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99379) provided on July 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Code 99379 is assigned a status indicator of B under the Physician 
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for 
other services. No separate payment can be made for these services.   
 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 (99379) provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) 
vaccine rendered on October 21, 2021. 
 
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 services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis 
(TDaP) vaccine rendered on October 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to hold you harmless for psychotherapy services (90834) provided on October 7, 
2021. 
 
You asked the Plan to hold you harmless for psychotherapy services. You say that the Plan is mistaken about 
the provider on the date of service. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for psychotherapy services by a contract provider. The file does not show that the Plan 
provided notice that psychotherapy services would not be covered. Under Medicare rules, this means 
psychotherapy services are considered approved by the Plan. Therefore, we decided that the Plan has to hold 
you harmless for psychotherapy services (90834) provided on October 7, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for Skilled Nursing Facility (SNF) Services provided 
from March 2, 2021, to March 27, 2021. 
 
You asked the Plan to reduce the cost for the Skilled Nursing Facility (SNF) Services. You say that the bill did 
not credit 23 days and $2,151.36 was billed for four days. You say that there was no reason to bill for room and 
board and it looks like the provider has double billed. The Plan denied your request. The Plan says the $184 
copayment applied correctly to March 22, 2021. The Plan also says that the SNF services from March 23, 
2021, through March 26, 2021 are not covered. 
 
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 rules say a plan must disclose to its enrollees in clear, accurate 
terms all cost sharing information (such as copayments, deductibles and coinsurance). 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. 
 
The enrollee has been asked to pay a $184 copayment for the SNF services provided on March 22, 2021, which 
was day 21 of the covered stay. SNF services falls within the "Skilled nursing facility (SNF) care" benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.  
 
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 SNF services provided from March 23, 
2021, through March 26, 2021. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found that based on the medical records provided daily skilled services were not required from March 
23, 2021, through March 26, 2021, due to her cognitive impairment and inability to participate with therapy. 
The services in the nursing facility from March 23, 2021, through March 26, 2021, were custodial. Therefore, 
we decided that the Plan does not have to reduce the cost for SNF services provided from March 2, 2021, 
through March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 6, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim lists the place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab testing services provided on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 30, 
2021 and billed under code 70450. 
 
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 a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists 
between 70496 and 70450. This PTP edit has a modifier indicator of 1, which indicates modifiers associated 
with NCCI are allowed, however, an appropriate NCCI modifier was not billed.  
 
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 modifier.  
In this case, this claim cannot be paid due to the omission of the required modifier. Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging 
services provided to the enrollee on September 30, 2021 and billed under code 70450.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee is 
undergoing a planned right hip arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the Inpatient Only List. The procedure 
is currently approved as an ambulatory procedure. There is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on July 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services rendered on September 17, 2021. 
 
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 procedure codes A0427 and A0425 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. 
 
In this case, the CPT Code Manual definition of code A0427 is ambulance service, advanced life support, 
emergency transport, level 1 [als 1 - emergency]). The definition of code A0425 is ground mileage, per statute 
mile. 
 
We find that CPT codes A0427 and A0425 are not supported in the medical record. Specifically, the billed 
service dates do not match the number of units billed. 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 ambulance services rendered on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in 
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, 
from L1 to L5.  This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal 
stenosis including the planned level of implantation at L3-4. FDA contraindications include spinal instability, 
scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no 
discussion of spinal instability on flexion/extension films. There is no discussion indicating that a DEXA scan 
has demonstrated the lack of significant osteoporosis in this enrollee. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device 
at L3-4 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
 We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials rendered on December 
21, 2020 to January 29, 2021. 
 
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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and 
clinical staff time over and above those usually included in an office visit or other non-facility service(s), when 
performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious 
disease) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan 
does not have to pay for the additional supplies and materials rendered on December 21, 2020 to January 29, 
2021.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation is insufficient to support that you require at least three (3) hours a day, five (5) days a week, or 
fifteen (15) hours over seven (7) consecutive days, of therapy services.  
 The available documentation does not support that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 waive the copayment for computed tomography (CT) scan of arm 
provided on December 14, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that after a second fracture was missed by 
your previous doctor. You also say that no one has volunteered to write off any of the charges. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $375 
copayment for a CT scan.  
 
 You have been asked to pay the allowed amount of $112.22, which is less than the $375 copayment for a CT 
scan. A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 computed tomography (CT) scan of arm 
provided on December 14, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.