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

 
We decided that the Plan does not have to pay for the evaluation and management services (99285) provided 
on October 14, 2021. 
 
You asked the Plan to pay for the evaluation and management services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the documentation does 
not support payment for CPT 99285 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 evaluation and management services. Our reviewer says 
that the documentation does not support the evaluation and management service that was billed for the services 
rendered. Our reviewer found the review indicates that the CPT should be down coded per Medicare billing 
regulations. In this case, the documentation indicates that the enrollee did not meet imminent danger to life or 
function criteria for CPT 99285. The review has determined that the documentation did not support payment 
for CPT code 99285 based on the services rendered. 
 
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 evaluation and management services have not been met. Therefore, we 
decided that the Plan does not have to pay for the evaluation and management services (99285) provided on 
October 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on November 21, 
2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 We find that CPT code 99285 is not supported in the medical record. Specifically, the claim submitted for the 
services rendered have a date of service of November 21, 2021; however, the documentation submitted shows a 
different date of service (November 18, 2021). This means that the documentation does not support the claim 
billed. Based on this information, we decided that Medicare rules for coverage of the emergency department 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department 
visit provided on November 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 19, 
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 provider did not bill as required by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on February 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel this is a necessity because you are in a lot of 
pain. You also say that you need to stay to start physical therapy and continue care. The Plan denied your 
request. The Plan says coverage cannot be provided for Inpatient Medical Rehabilitation Level of Care. 
 
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 at the current functional mobility level, you do not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. Our reviewer found that an IRF admission is not medically necessary based on medical stability and lack 
of medical complexity or nursing needs. Our physician reviewer also found that while you may benefit from 
physical therapy and occupational therapy, your rehabilitation needs can be met safely and provided at a lower 
intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 25, 2021. 
 
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 billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) interpretation and report 
(93010) provided on December 22, 2021. 
 
You asked the Plan to pay for the ECG report. You say that this service was billed appropriately and is 
supported in the record. The Plan denied your request. The Plan says a National Correct Coding Initiatives 
(NCCI) Procedure to Procedure (PTP) edit exists between 99152 and 93010. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was 
not billed with this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 93010 
is a column II code to column I code 99152. 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 the electrocardiogram (ECG) interpretation and report (93010) 
provided on December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4-S1 laminectomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no simple conservative therapy for at least six weeks in the past twelve 
months. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found not enough conservative measures have been tried and failed. More physical therapy is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4-S1 laminectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording up to 48 hours by 
continuous rhythm recording and storage; scanning analysis with report (CPT code 93226) provided on 
October 6, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee was under Hospice services on October 6, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the external electrocardiographic recording up to 48 hours by 
continuous rhythm recording and storage; scanning analysis with report (CPT code 93226) provided on 
October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive genomic profiling test provided on 
November 15, 2021. 
 
You asked the Plan to pay for the comprehensive genomic profiling test. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 pay for the comprehensive genomic profiling test. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of the sigmoid 
colon. FoundationOne CDx testing analyzes 324 genes as well as genomic signatures including microsatellite 
instability and tumor mutational burden. The documentation does not support that alternative laboratory or 
clinical tests to definitively diagnose the enrollee's disorder/identify the condition are unavailable or that the 
results are clearly equivocal. Additionally, the documentation is insufficient to support that the results of the 
testing would directly impact the treatment or management of this enrollee. Therefore, the enrollee did not 
meet criteria for the services rendered. 
 
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 comprehensive genomic profiling test have not been met. Therefore, we 
decided that the Plan does not have to pay for the comprehensive genomic profiling test provided on November 
15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services coded 86077 provided on 
 
You asked the Plan to pay for the blood bank physician services. You say that you would like the plan to 
reconsider their denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the 
blood bank physician services coded 86077 provided on
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy and lipectomy for the enrollee. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says the excess skin and soft tissue on the lower part of the abdomen has not been 
documented to cause impairment of physical function. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has excessive pannus die to weight loss following bariatric 
surgery in March 2021. The record does not indicate that the enrollee has a functional impairment or has 
intertrigo unresponsive to conservative medical treatment. Eighteen months has not passed since the bariatric 
surgery and the record indicates that her weight is fluctuating. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service at this time. The 
elements of the coverage criteria are not satisfied.  
 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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve panniculectomy and lipectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve eight chiropractic visits. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation when there is an expectation of 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 services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found you have pain and 
tightness in the low back. You were evaluated for new complaints in April 2022 and were diagnosed with 
lumbar, pelvis, and sacrum segmental dysfunction. Graphic documentation supports that you have had 
symptomatic exacerbations and remissions since 2017. There is documentation of one chiropractic visit in 
2018, two visits in 2019, one visit in 2020, two visits in 2021, and two visits in 2022, including the visit in 
April 2022. The documentation does not support that the requested services are for maintenance purposes, but 
rather that they are for treatment of an acute problem. Therefore, you meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve eight chiropractic visits.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 83520, 82656, 82705, 87177 
and 87209 provided on April 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 83520, 82656, 82705, 87177 and 87209 
provided on April 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a positron emission tomography (PET) scan.
You asked the Plan to provide coverage for a PET scan. You say that a PET scan was medically necessary. The
Plan denied your request. The Plan says Medicare coverage 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 a PET scan is not
covered as the initial imaging for treatment strategy in patients diagnosed with prostate cancer. This PET scan
was requested for that purpose. Therefore, we decided that the Plan does not have to provide coverage for a
positron emission tomography (PET) scan.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide 40 additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that you need this transportation in order to 
continue to go to your medical appointments. The Plan denied your request. The Plan says your benefit covers 
a maximum of 36 transportation trips per year. Additional trips are not a covered benefit. 
 
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 36 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 provide 40 additional routine transportation trips.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal tract imaging (91110) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a wireless capsule endoscopy is not covered for evaluation for tumors in the small 
bowel. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there were no records or data to support any manifestation or progression of carcinoid-related symptoms 
nor elevation in tumor markers to raise concern for carcinoid recurrence, nor that the prior colonoscopic 
resection was incomplete. No results from conventional imaging were provided. No records were provided to 
support that the enrollee is under consideration for peptide receptor radionuclide therapy (PRRT) with 
letetiuum Ludotate. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gastrointestinal tract imaging (91110) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says this claim has not been billed with an 
appropriate modifier as required by Medicare billing regulations. 
 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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head or brain (70450)