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

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service March 29, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. The Plan denied your request. The 
Plan says this code is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hyalgan supartz visco-3 injection. 
 
You asked the Plan to pre-approve a Hyalgan supartz visco-3 injection. 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 Hyalgan supartz visco-3 injection. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requirement is first to do a course of physical therapy and non-
steroidal anti-inflammatory drugs (NSAIDs) over a 3-month period. This has not yet been accomplished. 
Therefore, at this point, the request is deemed not medically reasonable and necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Hyalgan supartz visco-3 injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Hyalgan supartz visco-3 injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxychlor. 
 
You asked the Plan to pre-approve Hydroxychlor. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxychlor.  
 
Benefits for Hydroxychlor may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for the medical services provided from October 23, 2022, to 
November 27, 2022. 
 
You asked the Plan to reimburse you for the medical services. You say that you feel you should be reimbursed 
an additional amount. You say that the enrollee was in the intensive care unit or cardiac care unit the entire 
time they were in the hospital. You also say that you used your savings and credit cards to pay this bill. The 
Plan denied your request. The Plan says that you are responsible for any costs over what Original Medicare 
would pay. The Plan also says that no additional payment can be made. 
 
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, the Plan has not provided sufficient documentation to support how 
the payment that was made was calculated. Without this information, we cannot determine that the correct 
amounts were applied. Additionally, the Plan has not explained what information is missing or invalid. 
Therefore, we decided that the Plan has to reimburse you for the medical services provided from October 23, 
2022, to November 27, 2022, less the contractual cost sharing amount of $90.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 11, 2022, to 
April 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.21, described as acute 
and chronic respiratory failure with hypoxia. 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 hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the enrollee presented with shortness of breath. Acutely, she 
appeared to have recurrent pleural effusions. There is no evidence that the enrollee had overt respiratory failure, 
or that she required ventilatory support. As such, the diagnosis of J96.21 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 11, 2022, to April 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the parathyroid planar imaging (including subtraction, 
when performed); with tomographic (SPECT) (78071). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 service. Our physician reviewer 
found there were no provided lab reports to confirm the diagnosis of hyperparathyroidism or to support this 
request for advanced imaging such as an abnormal calcium, vitamin D, or parathyroid hormone (PTH) and no 
physical findings from examination suggesting a tumor or other indication for SPECT imaging. Therefore, the 
Medicare NCD requirements are not met. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the parathyroid planar imaging (including subtraction, when performed); with tomographic 
(SPECT) (78071).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the 
Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Health Plan. The Health Plan has approved ongoing 
care in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 25, 2022, to 
June 3, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with subacute diarrhea and abdominal pain and acute encephalopathy. Initial testing 
revealed diverticulitis with a possible small abscess. The enrollees vital signs were stable, and labs were 
without evidence of renal or liver failure. The enrollee was treated conservatively for the diverticulitis as well 
as for radiographic pneumonia. The enrollee does not appear to have been septic.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from May 25, 2022, to June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
January 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services are not supported without the required documentation. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 that the enrollee was evaluated for 
syncope. The history of present illness was brief, there was no review of symptoms and there was no 
comprehensive physical exam and no evidence of complex decision making. 
 
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 initial hospital care (procedure code 99223) rendered on January 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services from April 27, 2022, to May 26, 2022.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional documentation.
The Plan noted that Plan received and accepted a Notice of Admission on March 16, 2022, with an admission
date of January 27, 2022, listed. The Plan received a claim on June 10, 2022, with the admission date listed as
July 31, 2021. As the NOA admission date and the claim admission date are two entirely different dates and
months, Medicare billing criteria were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this claim
cannot be paid because of a discrepancy with the NOA dates reported. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services
provided from April 27, 2022, to May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on May 
1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223-25 (1 unit) 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 that no history and physical has been 
submitted for the date of service under review. Therefore, the billing of CPT 99223 on 5/1/2022 is not 
supported. 
 
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 initial hospital care (procedure code 99223) rendered on May 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6196, A6219, and A6212 billed for date of 
service October 27, 2022. 
 
You asked the Plan to pay for procedure codes A6196, A6219, and A6212. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes A6196, A6219, and A6212 is 
bundled into the payment for the physician service to which it is incident 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes A6196, A6219, and A6212 have a status indicator of P on the Physician Fee 
Schedule. This means that procedure codes A6196, A6219, and A6212 are not separately payable as billed. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A6196, A6219, and 
A6212 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
A6196, A6219, and A6212 billed for date of service October 27, 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. 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 clinical documentation does not specify any complex functional impairments or 
active medical comorbidities thus the complexity of the enrollee's documented nursing, medical and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. IRF criteria not met. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve eyelid repair (14060, 67917). 
 
You asked the Plan to pre-approve eyelid repair. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 eyelid repair. Our reviewer says that 
you have excessive tearing consistent with the ectropion. As such, the services are considered medically 
necessary. Our physician reviewer found you have excessive tearing consistent with the ectropion. As such, the 
services are considered medically 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 eyelid repair have been met. Therefore, we decided that the Plan has to pre-
approve eyelid repair (14060, 67917).  
 
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.