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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI. You say that an MRI is medically necessary. The Plan denied your 
request. The Plan says the requested MRI has been correctly denied. 
 
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. Our physician reviewer found 
there is a lack of evidence on whether other MRI findings changed from the previous MRI. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of HBO therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided 
records did not describe that your diabetes was under control, you have peripheral arterial disease (PAD) with 
reduced circulation to the leg, and you have not yet had the required 30 or more days trial of standard wound 
therapy to see if there is improvement or not before consider HBO therapy. Therefore, you have not currently 
meet coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of HBO therapy (99183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, & 88360 billed for date of 
service July 23, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, & 88360. You say that these services were 
medically necessary. 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, & 
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, & 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, & 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, & 88360 billed for date of service July 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test results inform treatment decisions. The 
Plan denied your request. The Plan says the claim did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met.  We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
October 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine revision surgery, to perform lumbar 
decompression with fusion at L2-3 and L5-S1 and prior fusion hardware removal at L3-5 level coded as 22633, 
22634, 63047, 63048, 22583, 22842, 20936 and 61783. 
 
You asked the Plan to pre-approve the surgical procedure. You say that you request reconsideration because the 
enrollee has known severe spinal stenosis and a spondylolisthesis with weakness. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for another surgery at this time. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the imaging studies do not show spinal instability on flex-extension films. There is no correlation between imaging and physical exam findings. A recent 6-week trial of physical therapy is also not 
documented. Medical necessity cannot be established. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spine revision surgery, to perform lumbar decompression with fusion at 
L2-3 and L5-S1 and prior fusion hardware removal at L3-5 level coded as 22633, 22634, 63047, 63048, 22583, 
22842, 20936 and 61783.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the services (99291) provided on May 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment for this 
service is included in the fee for the procedure. 
 
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 for this service is included in the fee for the 
procedure. However, the Plan has not provided any documentation showing that any procedure was performed 
on the date of service in question. The only other code billed for this date of service is 92950. The Plan has not 
shown that code 99291 is included in the payment for code 92950. As such, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the services (99291) provided on May 15, 
2020.  
 
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 subsequent hospital care (procedure code 99233) rendered 
from June 25, 2022, to June 26, 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 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 code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 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 this subsequent hospital care 
evaluation and management code requires two out of these three key components: a detailed interval history, a 
detailed examination and medical decision making of high complexity. In this case, the medical records 
submitted did not support a detailed interval history and medical decision making of high complexity. 
 
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 subsequent hospital care (procedure code 99233) rendered from June 25, 2022, to June 26, 
2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the optometry services and lenses/frames provided on 
January 10, 2023. 
 
You asked the Plan to hold you harmless for the items/services. You say that you feel that all the services 
provided should be covered. The Plan denied your request. The Plan says that the claim was processed 
correctly. 
 
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. In this case, the Plan submitted an Explanation of Benefits (EOB) from their 
third-party routine eye care administrator. However, this EOB was blank. Though the Plan lists out the denied 
amounts and explanations for the denials, Maximus is unable to verify what was paid or not paid without an 
EOB. In addition, the Plan indicates that certain services are not covered, but the services were rendered by a 
network provider, without any evidence that there was a clear exclusion of coverage that was explain to the 
enrollee at the time of purchase. Due to the missing information, we find that the Plan has not substantiated that 
the claim was processed correctly. Therefore, we decided that the Plan has to hold you harmless for the 
optometry services and lenses/frames provided on January 10, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rental charge for a transcutaneous electrical nerve 
stimulator (TENS) unit for the month beginning on November 22, 2022. 
 
You asked the Plan to pay for the TENS rental charge. You say that the services were medically necessary and 
ordered by the treating provider. The Plan denied your request. The Plan says the documentation submitted did 
not include a valid Proof of Delivery, or a Delivery Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The proof of delivery submitted does not indicate what delivery 
service was used. As such, it cannot be confirmed that it is legitimate. In addition, no progress note from 
around the date in which the order was signed is included in the file. The notes that are included do not make 
any mention that the enrollee has been prescribed or is using a TENS unit. The notes indicate that only 
medications are being used to treat her pain. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
rental charge for a transcutaneous electrical nerve stimulator (TENS) unit for the month beginning on 
November 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic services received from February 10, 2022, to December 
13, 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 that claim will be reconsidered if accident detail info is received from the enrollee. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for chiropractic services received from February 10, 2022, to 
December 13, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 2 standard, multiple power 
option, captains chair, patient weight capacity up to and including 300 pounds (K0842) and the other requested 
items/accessories (E1012, E1028, E2311, E2377, E2313, E2361, E1007). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The request for a replacement of the 
enrollee's current power wheelchair cannot be covered. The enrollee's current power wheelchair was delivered 
in November 2020. Per Medicare rules, a replacement of a power wheelchair due to wear is not covered during 
the reasonable useful lifetime of the equipment (less than 5 years). A new wheelchair is requested for use 
outside the home. Medicare does not cover items requested for use outside the home. Therefore, we decided 
that the Plan does not have to pre-approve the power wheelchair, group 2 standard, multiple power option, 
captains chair, patient weight capacity up to and including 300 pounds (K0842) and the other requested 
items/accessories (E1012, E1028, E2311, E2377, E2313, E2361, E1007).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service September 21, 2022. 
 
You asked the Plan to pay for code 99222. You say that the Plan should not have denied this claim. The Plan 
denied your request. The Plan says code 99222 is not supported by the medical record because the records don't 
support a comprehensive history and comprehensive examination. 
 
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. 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 code 99222. Our reviewer says that code 99222 is not supported by the medical 
record. Our reviewer found the enrollee was a then 69-year-old male with a history of chronic kidney disease Stage III who had a syncopal episode. He was evaluated in the emergency department and admitted. Current 
Procedural Terminology (CPT) code 99222 (1 Unit) was not supported. This initial hospital care evaluation and 
management code requires a comprehensive history, a comprehensive examination and medical decision 
making of moderate complexity. In this case, the medical records submitted did not support a comprehensive 
history and comprehensive examination. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram (ECG) (93010) provided on June 24, 2022. 
 
You asked the Plan to pay for the emergency department visit and ECG. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the claim must first be submitted to the 
enrollee's primary insurance. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has sent multiple 
requests to obtain documentation showing that the primary plan has processed the claim. As the secondary 
insurer, the Plan cannot be held responsible for the emergency department visit and ECG until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
emergency department visit (99285) and electrocardiogram (ECG) (93010) provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on May 19, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test has not met Medicare 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on May 19, 2022.