Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on December 28, 2021, 
and subsequent hospital care (99231) provided on December 29, 2021. 
 
You asked the Plan to pay for initial hospital care (99222) and subsequent hospital care (99231). You say that 
physicians in the same group but different specialties may bill and be paid without regard to their membership 
in the same group. You say that the claim should be paid since these providers belong to the same specialty and 
the claims were submitted with the same diagnosis. The Plan denied your request. The Plan says CPT codes 
99222 and 99231 are within the global period of 90 days of CPT code 36830. 
 
The Plan must follow Medicare rules. The rules state that The Medicare approved amount for procedures 
includes payment for the following services related to the surgery when furnished by the physician who 
performs the surgery. The services included in the global surgical package may be furnished in any setting.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care (99222) and subsequent hospital care (99231) have not been met. Specifically, 
CPT codes 99222 and 99231 were billed within 90 days of CPT code 36830 by the same provider. A modifier 
was not billed to indicate these services were unrelated. Therefore, we decided that the Plan does not have to 
pay for initial hospital care (99222) provided on December 28, 2021, and subsequent hospital care (99231) 
provided on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator (BGS). 
 
You asked the Plan to pre-approve the ultrasonic BGS. You say that your doctor feels this is needed due to 
your non-healing of your fracture. The Plan denied your request. The Plan says the documentation does not 
include imaging evidence to support a non-union. This BGS cannot be covered at this time. 
 
The Plan follows Medicare rules. Medicare rules say that ultrasonic BGS may be covered to treat nonunion of a 
fracture evidenced by a minimum of two sets of radiographs obtained prior to starting treatment with the 
osteogenesis stimulator, separated by a minimum of 90 days. 
 
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 ultrasonic BGS. Our reviewer says 
that the criteria for coverage of the requested ultrasonic BGS are not met in this case. Our physician reviewer 
found this 71-year-old male enrollee was being treated for displacement of other internal orthopedic devices. 
He is post-operative from the talonavicular fusion on the left foot. He continues to experience considerable 
swelling and pain. His second screw was removed 28 days ago. He rates his pain level at 8/10 regularly. He 
does note clicking and has slowed down considerably. He continues to minimize weight bearing as much as 
possible. The exam reveals localized swelling around the rear foot, centered over the previous surgical sites of 
talonavicular joint. Clicking or crepitus is not present on manipulation or palpation. 
 
However, detailed documentation is not evident regarding serial x-rays over a 3-month period evidencing no 
progressive healing to support the diagnosis of non-union at this time. There is no evidence in the available 
medical records that this patient would be considered at high risk for delayed fracture healing. Continuation of 
appropriate conservative fracture management was indicated at the time of this request. 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 criteria of the LCD are not met, and record does not include evidence 
that the requested device is medically reasonable and necessary in spite of LCD limitations. 
 
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 ultrasonic BGS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an ultrasonic bone growth stimulator (BGS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88360, and 88342 
provided on August 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
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. 
 
We find that CPT codes 88341, 88360, and 88342 are not supported in the medical record. Specifically, this 
claim was billed with a place of service 22 (outpatient hospital). These codes have a professional 
component/technical component of 1. This means these codes were billed with an incorrect place of service. 
The professional interpretation was furnished in the same payment locality from where the technical 
component was furnished. We find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting 
physician. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
88341, 88360, and 88342 provided on August 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
on February 25, 2021, and March 2, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that there was no therapy performed 
due to the immobilizer. 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 $40 
copayment for each therapy visit.  
 
The record shows that the two visits included treatment planning and education. Therefore, you have been 
asked to pay a $40 copayment for each visit for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services 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 copayments for physical 
therapy (PT) services provided on February 25, 2021, and March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99212) provided on 
January 28, 2022, by a chiropractor. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the Plan's denial of this charge is 
an error. The Plan denied your request. The Plan says the service at issue is not a covered benefit when 
provided by a chiropractor. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office or other outpatient visit (99212) provided on January 28, 2022, by a 
chiropractor.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided August 12, 
2021. 
 
You asked the Plan to pay for the emergency visit. You say that the claim was submitted well within the payer 
limits. Please review the attached showing proof of your due diligence to meet these filing requirements and 
override the denial. The Plan denied your request. The Plan says the enrollee elected hospice services on date 
of service 08/12/2021 therefore, Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the members terminal condition.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit (99284) provided August 12, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive your copayment for outpatient surgery performed on  
February 25, 2022. 
 
You asked the Plan to waive your copayment for outpatient surgery performed on February 25, 2022. You say 
that you do not feel responsible for this copayment. The Plan denied your request. The Plan says you must pay 
a $200 copayment for outpatient surgery at an ambulatory surgical center or outpatient hospital facility. 
 
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 $200 
copayment for Outpatient Surgery.  
 
You have been asked to pay a $200 copayment for outpatient surgery. A cystourethroscopy and needle biopsy 
fall within the Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 your copayment for outpatient 
surgery performed on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided November 3, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was a duplicate. 
 
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 CPT code 99204 is not supported in the medical record. Specifically, code 99204 was already paid 
for this date of service under claim 32919182-00. Records do not support multiple instances of this code. Based 
on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided November 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge for teeth numbers 5, 6, and 7 (comprised 
of two retainer crowns and a pontic for tooth 6). 
 
You asked the Plan to pre-approve the requested fixed bridge. You say that this should be approved due to 
medical necessity. The Plan denied your request. The Plan says the criteria for this bridge have not been met. 
 
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. The Plan covers the requested 
fixed bridge when the services are medically necessary and reasonable.  
 
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 requested fixed bridge. Our 
reviewer says that the documentation does not support that the requested bridge is necessary. Our physician 
reviewer found the enrollee has multiple teeth missing from the right upper jaw. The requested bridge is not a 
reasonable and necessary treatment for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the requested fixed bridge have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a fixed bridge for teeth numbers 5, 6, and 7 (comprised of two retainer 
crowns and a pontic for tooth 6).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a procedure to remove fat from the right leg 
(liposuction). 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered a cosmetic procedure. 
 
The Plan must follow Medicare rules. Medicare rules say cosmetic surgery or expenses incurred in connection 
with such surgery 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 pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the record indicates that the requested procedure is being performed for contouring 
purposes. The provided record supports that the requested procedure is cosmetic in nature. The elements of the 
coverage criteria are not satisfied. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a procedure to remove fat from the right leg (liposuction).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
device (K0554) and sensors (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and related supplies. You say that the requested 
items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for 
CGMs and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM and related supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) device (K0554) and sensors 
(K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammography and screening digital breast 
tomosynthesis provided on March 2, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the screening mammography and screening digital breast tomosynthesis. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
received are not a covered benefit when provided by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the screening mammography and screening digital 
breast tomosynthesis provided on March 2, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on December 30, 
2021. 
 
You asked the Plan to pay for subsequent hospital care (99231). You say that physicians in the same group but 
different specialties may bill and be paid without regard to their membership in the same group. You say that 
the claim should be paid since these providers belong to the same specialty and the claims were submitted with 
the same diagnosis. The Plan denied your request. The Plan says CPT code 99231 is within the global period of 
90 days of CPT code 36830. 
 
The Plan must follow Medicare rules. Medicare rules say that the rules state that the Medicare approved 
amount for procedures includes payment for the following services related to the surgery when furnished by the 
physician who performs the surgery. The services included in the global surgical package may be furnished in 
any setting.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital care (99231) have not been met. Specifically, CPT code 99231 was billed 
within 90 days of CPT code 36830 by the same provider. A modifier was not billed to indicate this service was 
unrelated. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231) 
provided on December 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to provide coverage for injections for pain management for the enrollee.
You asked the Plan to provide coverage for these injections. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct LCD criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of treatment. It is noted that the treatment provided on January 10, 2020, was for left sacroiliitis.
There is consistent documentation by the provider of sacroiliac pain and sacroiliac Radio Frequency Ablation
(RFA) procedures. The provider records the sacroiliac (SI) joint RFA procedure as a lumbar facet RFA and
miscoded the procedure in the medical records. The request using incorrect codes is also evident in the
submitted appeal request. The provider states, "we would like to drop the 3rd level L3 -L4 and do 64635 left
L4 -L5 and 64636 Left L5 -S1."
However, the medical records show no history of treatment at either the L3 -L4 or L4 - L5 levels. There is no
documentation of diagnostic MBB injections completed at these levels. The medical record clearly states the
intent is the treat the left SI joint. There is no documentation of diagnostic lumbar facet injections being
completed, only procedures performed to the left SI joint. The regulation is clear that the requested procedure is
not covered. Therefore, we decided that the Plan does not have to provide coverage for injections for pain
management for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) for the upper right, lower right and upper left quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you need this deep 
cleaning. The Plan denied your request. The Plan says that this service is not medically necessary. 
 
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. Specifically, a request for diagnostic quality films was sent to the Plan and no 
response was received. The submitted case file includes photocopies of x-rays which are insufficient for 
review. Thus, we are unable to review the medical necessity of this claim.  Therefore, we decided that the Plan 
has to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the upper 
right, lower right and upper left quadrants.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient readmission hospital care provided from June 1, 2021, 
through June 14, 2021. 
 
You asked the Plan to pay for these services. You say that the inpatient readmission hospital care was 
medically necessary. The Plan denied your request. The Plan says that the inpatient readmission hospital care 
provided was not medically necessary for the enrollee. 
 
The Plan follows Medicare Rules. Medicare rules say that an inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 these services. Our reviewer says that the 
inpatient readmission hospital care provided was medically necessary. Our physician reviewer found that the 
reviewed documentation indicates that the enrollee presented to the Emergency department on June 1, 2021 
after a fall. The evaluation revealed a left hip fracture. She was evaluated by Orthopedics and underwent 
surgery. Post-operatively her status changed to comfort measures. She was then discharged to hospice on  
June 14, 2021. The review has determined that the readmission was medically necessary and did not result 
from a premature discharge from the same hospital.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
the inpatient readmission hospital care provided from June 1, 2021, through June 14, 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.