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

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request 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 cardiac catheterization. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee had a negative radionuclide stress test in 2021, and a cardiac computed 
tomographic angiography (CTA) scan within the past year was negative for significant coronary artery disease. 
The medical records provided do not support the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this setting. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99221) provided on October 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment is 
included in another service. 
 
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 argues that payment is included in another service. However, the Plan 
has not provided documentation specifying which service payment for code 99221 is included in. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the services (99221) provided on October 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
October 5, 2022. 
 
You asked the Plan to pay for the emergency department visit. 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. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with 
primary diagnosis code I46.8 (cardiac arrest due to other underlying condition). This diagnosis code has a 
"code first" note, which means it is not acceptable as a primary diagnosis. The claim is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of the emergency department visit have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit 
coded 99285 provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a bilateral heart catheterization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee has not had any stress testing or non-invasive imaging of the 
coronaries. 
 
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 has not substantiated their denial in this case. The plan's denial 
justification indicates that they had medical records to use. The plan has not forwarded any medical records to 
MAXIMUS for review. Therefore, we decided that the Plan has to pre-approve a bilateral heart catheterization.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc procedure. 
 
You asked the Plan to pre-approve a Via Disc procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Via Disc procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that a VIA disc procedure is experimental for back pain. 
 
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 Via Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Via Disc procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service September 
25, 2022. 
 
You asked the Plan to pay for procedure code 99292. The Plan denied your request. The Plan says payment for 
code 99292 is bundled into payment for code 36620. 
 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 99292 
is a column II code to column I code 36620. 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 99292 billed for date of service September 25, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on September 26, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgery 
services are not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 31600. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon 
services provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on June 3, 2021, to June 4, 2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, this service was also billed 
by the same provider or provider group within the same specialty. Only one evaluation and management 
service is allowed for the same date of service per provider group within the same specialty. This means this 
claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay 
for the subsequent hospital care services coded 99232 provided on June 3, 2021, to June 4, 2021.
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 you need to additional care, more than can be 
provided at home. The Plan denied your request. The Plan says your records do not show that it is reasonable to 
expect that you will be able to safely participate in or fully benefit from the intensity of services of an IRF, 
medically necessary care may be provided safely in a different level of care. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (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. The Plan denied your request. The Plan says the records indicate 
requiring the intensity of therapy services provided at an inpatient rehabilitation and does not require full-time 
access to a rehab doctor or nurse, services needed can be safely met at a lower level of care. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on October 14, 2022. 
 
You asked the Plan to pay for the radiology services billed. You say that the claim was billed correctly and 
should be paid. 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 November 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 radiology service billed. have not been met. 
Therefore, we decided that the Plan does not have to pay for radiological services provided on October 14, 
2022.
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. The Plan denied your request. The Plan says the documentation 
shows that the enrollee's overall health is strong enough that you do not need hospital care. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for March 7, 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 procedure code 99152 is 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status. 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 procedure code 99152 billed 
for March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 20, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Medicare 
denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year 
from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until October 7, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on September 20, 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 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 enrollee 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95874 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 95874. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 95874 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95874 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95874 billed for date of service September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay at the inpatient behavioral health level of 
care. 
 
You asked the Plan to pre-approve continued stay at the inpatient behavioral health level of care. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued stay at the inpatient 
behavioral health level of care. Our reviewer says that the documentation does not support that the requested 
services are medically reasonable or necessary. Our physician reviewer found the enrollee was admitted to the 
acute inpatient psychiatric hospitalization on November 12, 2022, with Schizoaffective Disorder Unipolar 
Type. was not showing any dangerousness to self or others. He did him auditory no visual hallucinations and 
did not handle aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as he did not have any suicidal or homicidal thoughts. Based upon review the records provided, this patient 
does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of March 7, 2023, forward and could have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued stay at the inpatient behavioral health level of care have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued stay at the inpatient behavioral 
health level of care.