Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99232) provided on February 22, 2022, 
and February 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
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 use of codes 99223 
and 99232 is not supported by the records provided. Our reviewer found that the documentation does not 
support the level of service for 99223. In this case: History - Expanded problem focused; Exam - 
Comprehensive; MDM - Moderate complexity. For code 99232, the medical record does not include evaluation 
and management services provided on date of service billed, and therefore cannot be verified. 
 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 the services (99223, 99232) provided on February 22, 2022, and February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the calibrator solution/chips provided from July 3, 2022, to September 
20, 2022. 
 
You asked the Plan to pay for the calibrator solution/chips. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the records do not support the service billed. 
 
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. Review of the file shows that the Plan states that the records do not support the 
service billed. There is no explanation on why the items rendered are not supported. No Medicare rules were 
provided to support this denial. No other denial rationale was provided. The Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for the calibrator solution/chips provided from July 3, 
2022, to September 20, 2022.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 12, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not in hospice, and this 
was a medically necessary transport. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
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 ambulance services provided on June 12, 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 assistance with walking and speech, IRF 
services are needed until you recuperate. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Synvisc-One. 
 
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 Part B drug is not eligible for a Part D tier exception. 
 
The Plan must follow Medicare rules. The rules say that if payment for a drug could be available under Part A 
or Part B to the individual for such drug, then it will not be covered under Part D. 
 
We looked at the file and Medicare rules. The requested drug is covered under Part B and not eligible for a Part 
D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Synvisc-
One.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 74230 billed for date of service March 15, 2022.

You asked the Plan to pay for procedure code 74230. You say that a billing error denied as duplicate, 1 unit allowed per day and only one unit was done on March 15, 2022. 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 submitted claims in which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units.

In this case, the MUE for CPT code 74230 is 1. The MAI value for this code is 3. You did not provide all the required evidence showing that the excess units were actually provided, were correctly coded, and were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 74230 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 74230 billed for date of service March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says Although there are three 
approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollee has the mental capacity to operate the power wheelchair and no specialty 
controller is requested. Documentation shows that the enrollee has 4- to 4+/5 right upper limb strength, and 3 to 
4/5 left upper limb strength. The enrollees upper limb strength and function are adequate for the enrollee to 
be able to control the power options using their own switches which are included in the allowance of these 
power options.. This means that Medicare rules for coverage of wheelchair accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair 
controller and two or more power seating system motors (E2311), a harness (E2313) and an expandable 
controller (E2377).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve duplex scan of lower extremity arteries or arterial
bypass grafts; complete bilateral study (93925) for the enrollee.
You asked the Plan to pre-approve these services. You say that you have included detailed information to
support the medical necessity and reasons why this authorization denial should be reconsidered. The Plan
denied your request. The Plan says that the records do not support that the enrollee meets the criteria.
Our Medical director looked at the case file and the reopen request. At issues is coverage for duplex scan of
lower extremity arteries or arterial bypass grafts; complete bilateral study (93925). Our Medical Director states
that the clinical documentation is insufficient to support that the LCD criteria have been met in this case. An
ABI has not been shown to be abnormal. Our physician reviewer found that the enrollee's condition does not
meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study
(93925) for the enrollee.
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 are appealing with supporting records. The Plan denied your request. The Plan says that the record shows that you do not meet Medicare guidelines for services in an inpatient rehabilitation facility (IRF).
Maximus overturned the Plans denial stating IRF care would be necessary. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan is correct in this case. 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.
The rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The medical records indicate you would not be expected to be able to actively participate in and to benefit from an intensive rehabilitation therapy program. 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: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum pump (L5781), a multi-axial rotation unit
(L5986), and a shank-foot system (L5987) for a lower limb prosthesis.
You asked the Plan to pre-approve a vacuum pump, a multi-axial rotation unit, and a shank-foot system. You
say that the requested items are a necessity for your care. The Plan denied your request. The Plan says that
medical-necessity rules for the requested items have not been met. Maximus overturned the Plan's denial based
on prosthetist records. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that a determination
of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's
potential functional abilities. The record from your physician fails to show you are K3 functional ambulator.
Based on this information, we decided that Medicare rules for coverage of a vacuum pump, a multi-axial
rotation unit, and a shank-foot system have not been met. Therefore, we decided that the Plan does not have to
pre-approve a vacuum pump (L5781), a multi-axial rotation unit (L5986), and a shank-foot system (L5987) for
a lower limb prosthesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services 82306, 82607, 82728, 82746, 83036, and 83735 
billed for date of service June 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the services are not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The medical records provided show that testing was ordered after the enrollees yearly wellness exam. 
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or 
disease predisposition are not a Medicare benefit and are not covered. The testing at issue in this appeal was 
requested solely for screening purposes. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for lab services 82306, 
82607, 82728, 82746, 83036, and 83735 billed for date of service June 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
30, 2022. 
 You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoassay for tumor antigen testing (86304) provided 
September 28, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please see the attached medical record, 
which clearly supports the medical necessity of the denied claim. The Plan denied your request. The Plan says 
tumor antigen (86304) is not payable with the diagnosis codes of C50.911, Z17.0, and C79.51. 
 
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 find that CPT code 86304 is not supported in the medical record. Specifically, the claim was 
billed with the diagnosis codes malignant neoplasm of unspecified site of right female breast (C50.911), 
estrogen receptor positive status [ER+] (Z17.0) and secondary malignant neoplasm of bone (C79.51), which are 
not listed as covered diagnosis codes indicated in National Coverage Determination (NCD) Tumor Antigen by 
Immunoassay - CA 125 190.28. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
immunoassay for tumor antigen testing (86304) provided September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on the date in question. 
 
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 services provided on July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 16, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377), and expandable controller harness (E2313). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, and expandable controller 
harness. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories 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 an electronic connection, expandable 
controller, and expandable controller harness. Our reviewer says that the services are not medically necessary. 
Our physician reviewer found provided records document that the enrollee has 3+/5 to 5/5 upper extremity 
strength, and he is independent with feeding, dressing and bathing. Thus, indicating he has adequate upper 
extremity strength and function to operate the wheelchair's power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, expandable controller, and expandable controller 
harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller (E2377), and expandable controller harness (E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T and C1825). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that the device is medically necessary. 
The Plan denied your request. The Plan says the Barostim Neo device is considered unproven and 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 the Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's clinical 
management. 
 
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 Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device (0266T and C1825).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 31, 2022, to June 
7, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like this denial to be 
reversed. The Plan denied your request. The Plan says that the information received does not support that 
criteria were met for inpatient hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from May 31, 2022, to June 7, 2022.  
 
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.