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

 
We decided that the Plan does not have to pay for the hospital services billed as 99222 provided on June 10, 
2022. 
 
You asked the Plan to pay for the hospital services billed as 99222. You say that the documentation supports 
the services as billed. The Plan denied your request. The Plan says the medical records do not support the 
services 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. 
 
In this case, the CPT Code Manual definition of code 99222 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 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 problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 hospital services billed as 99222. Our 
reviewer says that the requested documentation does not support the hospital services as billed. Our reviewer 
found that the enrollee was a then, 66-year-old female with a history of hypertension, Asthma, and Hepatitis C. 
She was maintained on Methadone therapy due to prior opioid use. She was evaluated on June 10, 2022, for 
abdominal pain with associated nausea and vomiting. The initial hospital care evaluation and management code 
requires a comprehensive history, a comprehensive examination and medical decision making of moderate 
complexity. However, the medical records submitted do not include a comprehensive history. The review has 
determined that the documentation did not support the billed CPT code 99222. 
 
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 hospital services billed as 99222 have not been met. Therefore, we decided 
that the Plan does not have to pay for the hospital services billed as 99222 provided on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 14, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on June 27, 2022. 
 
You asked the Plan to pay for the testing services. You say that the drug screen provides valuable information. 
The Plan denied your request. The Plan says the test exceeds the needs of the enrollee. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. 
 
 We find that CPT code G0483 is not supported in the medical record. The records do not show that 22 drug 
classes were tested. The records do not show that the testing was based on side effects, suspicious behaviors, or 
a documented change in effect or behavioral pattern. The medical records show compliant behavior and an 
accurate pill count. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing provided on June 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous fusion using the ZIP Interspinous 
Fixation (22612). 
 
You asked the Plan to pre-approve the interspinous fusion using the ZIP Interspinous Fixation. You say that the 
service is medically necessary. The Plan denied your request. The Plan says this service is experimental. 
 
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 interspinous fusion using the ZIP 
Interspinous Fixation. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found ttere is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. The 
peer-reviewed literature stated that further studies are needed to corroborate the efficacy of ISP as compared to 
traditional surgical procedures. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. 
 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 interspinous fusion using the ZIP Interspinous Fixation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the interspinous fusion using the ZIP 
Interspinous Fixation (22612)..
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Injectafer injection.  
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no notes showing a trial and failure of oral iron. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document any trial and failure of oral iron replacement. The records do 
not support any of the other covered indications for intravenous iron. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Injectafer injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service July 31, 
2022. 
 
You asked the Plan to pay for procedure code 72170. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 72170 is bundled into payment for code 73501. 
 
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 72170 
is a column II code to column I code 73501. 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 72170 billed for date of service July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on July 15, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you shouldnt have to pay for this. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for Primary care provider visits for Medicare-covered services. 
 
You have been asked to pay a $10 copayment for office visit. This item/service falls within the Primary care 
provider visits for Medicare-covered 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 copayment 
for office visit provided on July 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder 
(code 73221). 
 
You asked the Plan to pre-approve an MRI of the right shoulder. You say that an MRI of the right shoulder is 
medically necessary. The Plan denied your request. The Plan says the requested MRI of the right shoulder does 
not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the right shoulder. Our 
reviewer says that an MRI of the right shoulder is not medically necessary. Our physician reviewer found that 
this 53-year-old female was being treated for pain in the right shoulder. She presented with persistent pain. The 
electromyography (EMG) shows evidence of a mild multilevel cervical radiculopathy without active 
denervation in the right upper extremity. However, detailed documentation is not evident regarding a trial and 
failure of recent, reasonable, and comprehensive less invasive conservative care measures. Moreover, there are 
no objective findings provided for review to support deficits of the right shoulder. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested imaging in this clinical setting. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested right shoulder MRI, in this case, is not medically reasonable 
or 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 an MRI of the right shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder (code 73221).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 11, 2021, to August 14, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says it is maintained the patient was without clear and consistent provider documentation support or clinical indicators related to the findings of a dysregulated 
systemic response to infection. 
 
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 diagnosis code A41.89. 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 documentation did not support a manifestation of systemic infection beyond that 
evidenced by SIRS criteria. Patient remained hemodynamically stable throughout admission. The review has 
determined that the records did not support that A41.89 (other specified sepsis) was an appropriate diagnosis 
for this stay.  
 
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 to the enrollee from August 11, 2021, to August 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74160 billed for date of service August 6, 
2022. 
 
You asked the Plan to pay for procedure code 74160. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 74160 is bundled into payment for code 74176. 
 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 74160 
is a column II code to column I code 74176. 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 74160 billed for date of service August 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is not medically necessary. 
 
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 mechanical ventilator. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found there is no 
documentation of chronic respiratory failure due to chronic obstructive pulmonary disease. 
 
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 mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 16, 2021, to September 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. 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 diagnosis code J96.01. 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 patient was described as in no acute distress, no respiratory distress, normal pulmonary 
effort, alert and normal breath sounds. The patient's chest x-ray showed no appreciable change in patchy 
opacities in the right lung. She was diagnosed with acute cystitis and multiple fractures of pubic rami and 
admitted for further care. Vital signs included respiratory rate of 17-22 and SpO2 of 90-98%. History and 
Physical noted no respiratory distress and normal pulmonary effort. The review has determined that the records 
did not support that J96.01 (acute respiratory failure with hypoxia) was a reasonable secondary diagnosis code 
for this stay.  
 
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 to the enrollee from September 16, 2021, to September 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment ($298.63) charged for hospital services
provided from December 31, 2021, to January 1, 2022.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the
Plans denial. The Plan requested a reopen and provided additional information.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that you must pay a $325 copayment per day for days 1 to 5 of an inpatient stay.
The Plan provided documentation to show you were an inpatient on the dates of service in question. In this case
you are being charged less than the normal copayment expectation. 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 cost share
charged for hospital services provided from December 31, 2021, to January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravascular ultrasound and angiography provided to the 
enrollee on October 27, 2021. 
 
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 records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 37252: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to 
code for primary procedure) 
 
CPT 75710:  
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 CPT 75710 codes for diagnostic 
angiography of a unilateral extremity and is considered bundled within the intervention code 37252 (already 
billed and covered) unless there was no prior angiography or there was a change in condition. In this case, the 
patient underwent angiography of the right lower extremity only 6 months prior.  There is documentation that 
the patient has a left leg ulcer however this intervention was on the right leg and there is no documentation of 
any change in condition in the history and physical narrative. A diagnosis code or indication listing 
unsupported by the office visit note is not sufficient to meet this criterion. In terms of CPT 37252, this codes 
for supervision and interpretation of intravascular ultrasound. The documentation does not provide any 
interpretation of the ultrasound images and therefore the documentation does not meet a minimal threshold to 
justify use of the code. 
 
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 intravascular ultrasound and angiography provided to the enrollee on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 code 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service March 22, 2022.