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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intense rehabilitation and is 
dangerous to be discharged to home with the current condition. The Plan denied your request. The Plan says 
the enrollee's records do not show that you need an intensive team for your care, services needed can be 
provided safely in other settings, at a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable cervical collar billed with code L0180 for 
September 27, 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 were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of cervicalgia 
and underwent transforaminal nerve root injections on August 24, 2022. He complained of neck pain with 
paresthesia in his fingertips on September 7, 2022. The clinical records do not include examination of the neck 
of the upper extremities. The submitted clinical documentation is limited and does not support that the cervical 
collar was reasonable and medically necessary for the enrollee. 
 
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 pay for the adjustable cervical collar billed with code L0180 for September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement continuous positive airway pressure 
(CPAP) supplies coded as A7035, A7036, A4604, A7039, A7045, A7046, A7030, A7031, A7032, A7038. 
 
You asked the Plan to pre-approve the replacement CPAP supplies. You say that the following dispensable 
equipment is necessary for the proper use of the equipment and needs to be replaced on a regular basis. The 
Plan denied your request. The Plan says the available records show that the enrollee did not compliance 
criteria. 
 
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 replacement CPAP supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
CPAP equipment meets all Medicare criteria for medically reasonable and necessary for the enrollee. The 
provided records in this case do not document use of PAP for 4 hours per night on 70% of nights during a 
consecutive thirty (30) day period as required by the Local Coverage Determination (LCD) Positive Airway 
Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea L33718. Also as stated in the LCD: 
"Accessories used with a PAP device are covered when the coverage criteria for the device are met. If the 
coverage criteria are not met, the accessories will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the replacement CPAP supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the replacement continuous positive airway pressure (CPAP) supplies 
coded as A7035, A7036, A4604, A7039, A7045, A7046, A7030, A7031, A7032, A7038.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health treatment from April 
26, 2023. 
 
You asked the Plan to pre-approve continued inpatient mental health treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental health 
treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
upon review of the records provided the enrollee does not meet the criteria for April 26, 2023 forward as this 
enrollee was not shown to be a danger to herself or others. There were no delusions, auditory or visual 
hallucinations noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health treatment from April 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service November 10, 2022. 
 
You asked the Plan to pay for code 99284. You say that you disagree with the down-coding and provided 
medical records to support the original code billed. The Plan denied your request. The Plan says billed code 
99284 was not supported in the medical record, and the claim was down-coded to code 99283. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires the following 3 components: a detailed history; a detailed 
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 99284. Our reviewer says that code 99284 was not supported by the medical record. Our reviewer found code 99284 requires 3 out of 3 of the following: a 
detailed interval history, a detailed examination and medical decision making of moderate complexity. A 
detailed interval history requires 4+ elements or 3+ chronic conditions in the history of present illness, 2-9 
review of systems and 1 pertinent element of past, family and social history. A comprehensive examination 
requires 6 body areas or organ systems and medical decision making of moderate complexity requires multiple 
diagnoses or management options, a moderate amount and complexity of data reviewed and moderate risk of 
complication. The provided records document a fall with injury to the left knee and leg. Clinical examination 
and radiographic images were not consistent with any bony injury or other underlying issue such as loss of 
consciousness or head injury. The patient was treated with Tylenol, naproxen, tramadol and a knee immobilizer 
and discharged to home. The provided records in this case document a detailed interval history and a detailed 
examination. The provided records in this case do not document multiple diagnoses or management options, a 
moderate amount and complexity of data reviewed and moderate risk of complication.  
 
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 99284 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99284 billed for date of service November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
requested Group 3 power wheelchair with multiple power options is necessary for the enrollee's medical needs. 
The Plan denied your request. The Plan says the requested power wheelchair with multiple power options is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria have been 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 a Group 3 power wheelchair. Our 
reviewer says that a Group 3 power wheelchair with multiple power options is not medically necessary. Our 
physician reviewer found that the enrollee requires a power wheelchair for mobility and accomplishing daily 
activities. The reviewer found that the clinical documentation is insufficient why a lower-level power 
wheelchair would not suffice for the enrollees needs versus a Group 3 power wheelchair. The reviewer found 
there is inadequate clinical documentation regarding why the enrollee requires power tilt and recline and cannot 
perform pressure relief. The reviewer found the enrollee has no history of skin breakdown and does not have 
impaired sensation. There is also no significant lower extremity edema or spasticity that would require power 
elevating leg rests. Therefore, the reviewer found that the requested Group 3 power wheelchair with power tilt 
and recline and power elevating leg rests is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service July 14, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service July 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI, spinal canal and contents, lumbar; without contrast 
material (72148-26-77) provided on September 16, 2022. 
 
You asked the Plan to pay for the MRI. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 find that CPT code 72148 is not supported in the medical record. Review of the file shows that the medical 
records does not include documentation to support that the MRI, spinal canal and contents, lumbar; without 
contrast material was performed on the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for the MRI, spinal canal and contents, lumbar; without contrast material (72148-26-77) provided on 
September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim was underpaid. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 15, 2022.  
 
Your complaint about underpayment of the other code billed on the claim for this date of service is not a valid 
appeal for medical coverage. Maximus provides independent review for coverage disputes between Plans and 
enrollees. A coverage dispute is one in which the Plan does not pay for or approve an item or service because it 
believes that the item or service is not covered by Medicare and is not covered as an additional benefit under 
the terms of the Plans Evidence of Coverage. A non-contract provider who has been denied payment may 
appeal to the Plan if the provider executes a waiver of liability. 
 
A claim processing dispute is one in which the Plan agrees that the service is covered, but the amount of 
payment is in dispute. We have looked at your request and have determined your complaint about being 
underpaid for other codes on this claim is a claim processing dispute rather than a coverage dispute. Maximus 
does not have jurisdiction over these issues. You may contact the New York CMS Regional Office at 212-616-
2222 with any questions you have about this dispute.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous serum eye drops. 
 
You asked the Plan to pre-approve autologous serum eye drops. You say that the requested autologous serum 
eye drops are medically necessary. The Plan denied your request. The Plan says the requested autologous 
serum eye drops are 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 autologous serum eye drops. Our 
reviewer says that the requested autologous serum eye drops are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you have a history of anterior basement membrane 
dystrophy of the cornea and cornea scarring in both eyes. You have been using autologous serum tear drops 
and you are now requesting coverage and reimbursement through Medicare. Although autologous serum tear drops may serve beneficial for your condition, it is not medically necessary. Other equivalent treatment options 
are available, including artificial tears, gels, and lubricating ointment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of autologous serum eye drops have not been met. Therefore, we decided that the 
Plan does not have to pre-approve autologous serum eye drops.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections (64494, 64493). 
 
You asked the Plan to pre-approve facet block injections. 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 the primary indication of a diagnostic facet joint 
procedure is to diagnose whether the patient has facet syndrome. 
 
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 facet block injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records show that the 
enrollee did not have a consistent positive response of at least 80% relief of primary (index) pain (with the 
duration of relief being consistent with the agent used. The review has determined that the enrollee does not 
meet the 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 facet block injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet block injections (64494, 64493).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of the patients back pain is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. It is unclear from the medical record what type of device the enrollee currently has. The records also 
do not include a usage compliance report. The adaptive support ventilation (ASV) mode of ventilation can be 
delivered with advanced bilevel positive airway pressure (BiPAP) devices. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.