Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of swallowing dysfunction and/or oral function for feeding coded 92526 provided from September 21, 2021, to September 30, 2021.
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. 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 providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of code 92526 is treatment of swallowing dysfunction and/or oral function for feeding. We find that code 92526 is not supported in the medical record. Specifically, the claim was not submitted with the required modifier to process and pay claim, which caused the claim to deny. Per Medicare guidelines a GN modifier is required. Based on this information, we decided that Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the treatment of swallowing dysfunction and/or oral function for feeding coded 92526 provided from September 21, 2021, to September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247, 36248, 75716, 75774, and 75625, 
billed for date of service April 19, 2022. 
 
You asked the Plan to pay for procedure codes 36247, 36248, 75716, 75774, and 75625. The Plan denied your 
request. The Plan says the services are not payable as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
36247, 36248, 75716, and 75774 are column II codes to column I code 37229. Based on the claim submitted, 
Medicare billing criteria have not been met. 
 
In this case, the CPT Code Manual definition of code 37229 is "Aortography, abdominal, by serialography, 
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 procedure codes 36247, 36248, 75716, 75774, and 75625. 
Our reviewer says that the use of code 75625 is not supported by the records provided. Our reviewer found that 
this service was only documented as "the abdominal aorta is widely patent", which does not support the coding 
of procedure code 75625. As per the CPT procedure code guidelines, the procedure should be documented as 
"the provider makes an incision into the groin and breaks the common femoral artery using a needle. he inserts 
a guide wire and advances a catheter through the guidewire into the femoral artery. The provider advances up 
into the abdominal aorta. He then injects a contrast into the vessel and takes several images via serial 
radiography technique" The medical record does not include this description, and therefore, the procedure code 
could not 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 procedure code 75625 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 36247, 36248, 75716, 75774, and 75625, billed for date of service 
April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 30, 2021, 
to December 2, 2021, 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 
diagnosis was consistently documented in the medical record. The Plan denied your request. The Plan says the 
records do not support the diagnosis 
 
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 with the secondary diagnosis code J96.01, defined as acute 
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 physician reviewer found the enrollee presented to the 
hospital with a cough and chest pain. The history and physical documents a maximum respiratory rate of 29. 
The physical exam documents no respiratory distress, symmetric chest rise. The assessment documents acute 
hypoxic respiratory failure on 6 liters oxygen. While the medical record supports that the enrollee was hypoxic, 
the documentation does not sufficiently support a diagnosis of acute respiratory failure with hypoxia. The 
enrollee was in no acute distress. There is no documentation of an arterial blood gas (ABG). There is no 
documentation of a pulmonary consultation. A cardiology consultation was obtained and does not document 
respiratory distress. Therefore, the records do not support the billed diagnosis.   
 
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 November 30, 2021, to December 2, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral nutrition supplies billed for services from March 
25, 2022, to March 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that supporting medical records were provided. The 
Plan denied your request. The Plan says the billed codes are not supported. 
 
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 proof of delivery for the supplies provided in this case. 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 enteral nutrition supplies billed for services from March 25, 2022, to 
March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from  
May 22, 2022, to May 24, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you were told you are 
responsible to pay this because you were not able to share a room due to having COVID. You also say that 
there was no choice offered regarding this hospital choice or room situation. 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 have a $1,300 
maximum out-of-pocket. Your contract with the Plan also clearly says that you must pay 15% coinsurance for 
inpatient hospital care. The record shows your maximum out-of-pocket was met during the processing of this claim. You have been 
asked to pay $760.73, which is less than the 15% coinsurance for inpatient hospital care received from May 22, 
2022, to May 24, 2022. This item/service falls within the inpatient hospital care 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 coinsurance for inpatient hospital care provided from May 22, 2022, to May 24, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve acute inpatient hospital care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met. Our physician reviewer 
found the enrollee presented to the emergency department on November 3, 2022 with chest pain. His blood 
pressure was elevated and he was treated with oral medications. His electrocardiogram (EKG) was without any 
acute ischemic changes and troponins were normal. The records do not support a reasonable expectation that the enrollee will require at least two midnights of inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve acute inpatient hospital care.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided from May 31, 2022, 
and June 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support medical necessity. The Plan 
denied your request. The Plan says that this code excludes services provided in the emergency department. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient. We find that CPT code 99214 is supported in the medical record. 
The rules say that CPT code 99214 is not recognized by the outpatient prospective payment system (OPPS) 
when submitted on an outpatient hospital Part B bill type. However, the claim in this case does not show CPT 
code 99214 was billed on an outpatient hospital claim. Based on this information, we decided that Medicare 
rules for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for the 
evaluation and management services provided from May 31, 2022, and June 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (97598) provided on June 15, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the code billed is an add-on code billed without a primary procedure. 
 
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 97598 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for outpatient services (97598) provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examination, unilateral or bilateral, with 
interpretation and report; extended examination provided on February 24, 2022. 
 
You asked the Plan to pay for a visual field examination, unilateral or bilateral, with interpretation and report; 
extended examination. The Plan denied your request. The Plan says the Plan did not receive a primary carriers 
Explanation of Benefits. 
 
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 not received 
a primary carriers Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for a 
visual field examination, unilateral or bilateral, with interpretation and report; extended examination until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for a visual field examination, unilateral or bilateral, with interpretation and report; extended examination 
provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injections (ESIs) in the thoracic 
spine (62321 x 2 units). 
 
You asked the Plan to pre-approve ESIs. You say that this was denied based an a magnetic resonance imaging 
(MRI) that was taken 4 years ago. You say that you are in so much pain that you cannot work. You say that you need this to be approved as your pain level is at a 10, seven days a week. The Plan denied your request. The 
Plan says the ESIs are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the requirements 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 ESIs. Our reviewer says that the 
requested ESIs are not medically necessary. Our physician reviewer found the provided documentation 
indicates that your most recent magnetic resonance imaging (MRI) was 2 years old. A more recent MRI is 
necessary. Therefore, the reviewer found that the requested ESIs are not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injections (ESIs) in the thoracic spine (62321 x 2 units).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand x-ray rendered on May 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 73130 has an OPPS status indicator of Q1 and 
was billed with code 99283, which has an OPPS status indicator of V. Code 73130 therefore has no separate 
payment. Therefore, we decided that the Plan does not have to pay for the hand x-ray rendered on May 29, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kisqali. 
 
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 self-administered drugs are not covered. 
 
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 Kisqali.  
 
Benefits for these services 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from July 4, 2021, to August 2, 
2021. 
 
You asked the Plan to pay for the services provided. You say that there is nothing wrong with the dates. The 
Plan denied your request. The Plan says that the through date is incorrect. 
 
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. 
 
We looked at the file and the rules. The rules say that the "through" date must be 29 days after the "from" date 
for a 30-day period of care. We find that the through date, August 2, 2021, is 29 days after the from date, July 
4, 2021. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the home 
health services provided from July 4, 2021, to August 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for inpatient care and self-administered drugs 
provided from February 15, 2022, to February 18, 2022. 
 
You asked the Plan to pay the full cost for inpatient care and self-administered drugs. You say that you cannot 
afford these charges. 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 $372 
copayment per day for days 1 to 5 of inpatient hospital care. The also rules say that Medicare Part B generally 
does not pay for self-administered drugs.  
 
You have been asked to pay a $372 copayment per day for two days of inpatient care for a total of $744. This 
item/service falls within the inpatient hospital care 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. You have also been asked to pay $66.16 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 pay the full cost for inpatient care and self-
administered drugs provided from February 15, 2022, to February 18, 2022.  
 
Benefits for self-administered drugs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (15271) provided on March 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15271 is "Application of skin substitute graft to trunk, 
arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area". 
 
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 code 15271 is 
not supported by the records provided. Our reviewer found that the operative report states that the allograft area 
was 2250 sq. cm. CPT code 15271 only covers 100 sq. cm. 
 
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 (15271) provided on March 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (62323). 
 
You asked the Plan to pre-approve the repeat epidural steroid injections. You say that the service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections are covered when 
the first injection directly and significantly provided improvement of the condition being treated and when the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in 
function.  
 
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 repeat epidural steroid injections. 
Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found 
records show the prior injections did not provide sustained pain relief and did not meet the Medicare criteria of 
50% pain relief for 3 months. 
 
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 repeat epidural steroid injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat epidural steroid injections (62323).