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

 
We decided that the Plan does not have to pay for the office visit (99212), x-ray exam of the cervical spine 
(72040), and the electrical stimulation (G0283) provided on June 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the allowable 
benefit for these services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. However, the Plan provides supplemental coverage 
of 20 routine chiropractic visits per plan year.   
 
Though the Plan offers a chiropractic benefit that exceeds Medicare coverage, certain limitations apply. The 
records shows that the benefit was exhausted on date of service May 16, 2022.  Specifically, a maximum of twenty routine chiropractic visits are allowable per year. The enrollee received 20 
routine chiropractic visits from January 3, 2022, through May 16, 2022, which were paid for by the Plan with 
the annual deductible applied. Therefore, the enrollee has exhausted the allowable benefit for these services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99212), x-ray exam of the cervical 
spine (72040), and the electrical stimulation (G0283) provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care and testing services rendered on April 3, 
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 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 May 3, 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 these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care and testing services rendered on April 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation. The Plan denied 
your request. The Plan says admission to the IRF did not meet the Medicare criteria and the enrollee's needs 
can be met at home with supervision and home health services. 
 
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 clinical documentation shows that the enrollee has functional impairments, 
however there are no listed complex functional deficits that would require intense therapy or interdisciplinary 
team management in an IRF. All medical conditions are listed as stable without any documentation to show 
that the enrollee would continue to require inpatient hospitalization during rehabilitation. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have 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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. There is not a reasonable expectation that the enrolleewill 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the CGM and supplies (CPT code(s): K0553 and K0554). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM is necessary. The Plan denied 
your request. The Plan says that your request is not medically necessary because the enrollee's records show 
they have not been compliant with their Insulin. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our physician 
reviewer found it does appear as if the CGM would help this enrollee who has been unable to follow four (4) 
shots a day regimen and likely was not checking blood glucose (BGS) with a glucometer. 
 
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 CGM and supplies have been met. Therefore, we decided that the Plan has 
to pre-approve the CGM and supplies (CPT code(s): K0553 and K0554).  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (D5820), prefabricated abutment
(D6056), abutment supported retainer(D6068) and pontics (D6245) provided on August 3, 2021.
You asked the Plan to pay for these services. You say that these dental services should be covered by the Plan.
The Plan denied your request. The Plan says the services provided were not covered under the dental benefit.
Maximus partially overturned the Plans denial. The Plan requested a reopen and stated the contract is clear that
the services provided are not covered. The Plan also stated you signed a financial agreement with the provider
indicated you would be liable for full payment if any of the services provided were not covered by insurance.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among
those covered under this benefit. You were given a financial agreement by the provider referring to the fact that
you would pay for any non-covered services. Therefore, we decided that the Plan does not have to pay for the
interim partial denture (D5820), prefabricated abutment (D6056), abutment supported retainer
(D6068) and pontics (D6245) provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic leg with advanced foot and 
ankle. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that advanced foot and ankle features are covered 
when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not contain a physician 
progress note that support that the enrollee is a K3 ambulator. He has been an amputee since 2014 and it is not 
clear that he has been able to ambulate without an assistive device. The documentation does not support that 
the enrollee's functional needs cannot be met with a lower K level foot. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a replacement prosthetic leg with advanced foot and ankle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles. 
 
You asked the Plan to pre-approve the items. You say that there is a history of almost daily falls. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve push handles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 2, 2021, to July 6, 
2021, as billed with diagnosis related group (DRG) 100. 
 You asked the Plan to pay for inpatient care billed with DRG 100. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 100 is not 
appropriate as the diagnosis of acute respiratory failure, unspecified, whether with hypoxia or hypercapnia 
(J96.00) is not supported in the medical record. The Plan argues that DRG 101 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 100. Our 
reviewer says that the diagnosis of diagnosis of acute respiratory failure, unspecified, whether with hypoxia or 
hypercapnia (J96.00) is not supported in the medical record for this inpatient admission. Our physician 
reviewer found that the enrollee with a history of seizure disorder presented to the emergency department after 
being found at home with generalized seizure for 25-30 minutes. The enrollee was given Versed by emergency 
medical services and was described as in no acute distress, with unlabored pulmonary effort, lung sounds clear 
to auscultation, and a Glasgow Coma Scale (GCS) score of 8. The enrollee was intubated in the emergency 
department for airway protection and progress notes indicate that the enrollee had respiratory failure due to 
mental status changes and seizures. The enrollee was extubated on July 3, 2021. Progress notes indicate that 
after extubation, oxygen saturation remained greater than 94%. While it was acknowledged that the physician 
documented the diagnosis of acute respiratory failure, this diagnosis was not sufficiently supported by the 
medical record documentation. The review has determined that the medical records did not support the billing 
of acute respiratory failure, unspecified, whether with hypoxia or hypercapnia (J96.00). 
 
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 care billed with DRG 100 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 2, 2021, to July 6, 2021, as 
billed with diagnosis related group (DRG) 100.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a manual wheelchair coded with E0966, E0971, E1161 and 
E0974. 
 
You asked the Plan to pre-approve a wheelchair. You say that you received a letter that the authorization was 
denied, and you would like to appeal the denial of the wheelchair. The Plan denied your request. The Plan says 
that the medical necessity criteria was not met because of lack of clinical information to support the request. 
 
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 case file provided did not show that the Plan made any attempts to obtain 
medical records from either the provider or the enrollee. Therefore, we decided that the Plan has to pre-approve 
a manual wheelchair coded with E0966, E0971, E1161 and E0974.  
 
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 pay for procedure code 70450 billed for date of service June 25, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles (K0108), a power seat elevation feature 
(E2300) and powered leg rests (E1012) for a power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair features.. You say that the features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Elevating leg rests are covered when medically 
necessary. Medicare rules state that a power seat elevation feature (E2300) and power standing feature (E2301) 
are non-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 power wheelchair features.. Our 
reviewer says that the requested features are not medically necessary. Our physician reviewer found there is no 
significant edema or impaired knee flexion. The enrollee has normal posture. Power seat elevation features are non-covered and the requested push handles are a convenience item and are non-covered. 
 
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 power wheelchair features. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve push handles (K0108), a power seat elevation feature (E2300) and 
powered leg rests (E1012) for a power wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 9, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider is not 
part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 5, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric care provided from December 8, 
2021, through December 22, 2021. 
 
You asked the Plan to pay for the inpatient psychiatric care. You say that you were not able to obtain 
authorization as the enrollee's coverage was not known until after he was discharged. The services rendered 
were medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the Plan 
requires prior authorization for inpatient mental health services and authorization for such care to be provided 
out-of-network (OON). This was not obtained. Therefore, the stay was correctly denied. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient psychiatric care. Our reviewer 
says that the medical records support that the enrollee's medical condition was stable enough for transfer to a 
network facility as of the date of admission. Our physician reviewer found the enrollee was a then 68-year-old 
man who was admitted for acute inpatient psychiatric hospitalization on December 8, 2021, with Major 
Depressive Disorder, Recurrent, Severe without Psychotic Features, and Alcohol Abuse. The enrollee is noted 
to have been transferred from an external emergency department. The enrollee was in no acute distress. He was 
noted to be irritable and uncooperative. Judgement and impulse control were inadequate at the time of 
admission. Vital signs were not actionable. Laboratory results did not show any significant abnormalities. The 
enrollee was admitted with Major depressive disorder, recurrent severe without psychotic features.  
 
While the inpatient mental health services at issue were medically necessary and were needed as the result of 
an emergency condition, the documentation clearly shows that he was medically stable to be transferred to a 
network facility. 
 
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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient psychiatric care provided from December 8, 2021, through 
December 22, 2021.