Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you have provided documentation to support 
payment. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for 
code 99223. 
 
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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99072 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99226 billed for February 12, 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 procedure code 99226 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 99226 is Subsequent observation 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 these services. Our reviewer says that procedure code 99226 
is not supported. Our reviewer found CPT code 99226 can be used for subsequent observation care, per day, for 
the evaluation and management of a patient. The code can be used if the evaluation and management of a 
patient requires at least 2 of these 3 key components: a detailed interval history, a detailed examination, and 
medical decision making of high complexity.  The member is usually unstable or has developed a significant 
complication or new problems.  The time spent at bedside or on the unit is usually at least 35 minutes. In this 
case, the documentation does not support the CPT code 99226. The enrollee was medically stable and 
responded appropriately to treatment. 
 
We looked at this coder'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 procedure code 99226 billed for February 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 23420 and 29823 billed for date of service 
February 9, 2022. 
 
You asked the Plan to pay for procedure codes 23420 and 29823. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the available 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 23420 is: Reconstruction of complete shoulder (rotator) 
cuff avulsion, chronic (includes acromioplasty) and of code 29823 is: Arthroscopy, shoulder, surgical; 
debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid 
bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
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 23420 and 29823. Our reviewer says that 
the codes at issue do not meet criteria for payment. Our reviewer found that with regard to procedure code 
23420, the operative report does not include enough documentation to confirm complete shoulder 
reconstruction was performed.With regard to procedure code 29823, the operative report does not include 
documentation of extensive debridement. 
 
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 codes 23420 and 29823 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 23420 and 29823 billed for date of service February 9, 
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF admission 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 address the medical records that state the enrollee did not have acute medical issues requiring close evaluation by a rehabilitative doctor, and did not require intensive services as evidenced by his ambulatory status and need for contact guard assistance during lower body activities of daily living.
The Plan is correct in this case. 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. Whether or not IRF admission would be beneficial or not is not of issue. Enrollees must meet the specific coverage criteria required by Medicare. Based on the medical records provided, the enrollees condition did not require an IRF level of care. Medicare rules for coverage of IRF care were not met at the time of the appeal. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 17, 2022, billed with 
codes 81314, 81345, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 17, 2022, billed with codes 81314, 81345, and 81272.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade, 
electronic connection, and power seat elevation system. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that an expandable controller is used to control multiple power options. 
 
The power seat elevation system does not serve a purpose that is primarily medical in nature. The expandable 
harness is not needed to control the approved power switches. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller with harness upgrade, electronic connection, and power seat 
elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis, not otherwise specified 
(L5999). 
 
You asked the Plan to pre-approve an alignable system. You say that you disagree with the denial. The Plan 
denied your request. The Plan says notes do not show that the enrollee has an alignable system with current 
prosthesis. L5910 appears reasonable and necessary and is approved. The L5999 heavy duty system is 
unbundled from approved prosthesis and remains denied. 
 
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 an alignable system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found code L5999 must not be used to bill for any features or functions included in the 
socket or addition codes. Use of L5999 is incorrect coding (unbundling). The requested heavy-duty system 
does not serve a primary medical need. The requested heavy duty system exceeds the enrollee's medical needs 
and does not meet the criteria per LCA  A52496 and Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 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 an alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lower extremity prosthesis, not otherwise specified (L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 provided on October 14, 2022. 
 
You asked the Plan to pay for procedure code 83520. You say that the medical records support the billing of 
code 83520. The Plan denied your request. The Plan says the medical records do not support the billing of code 
83520. 
 
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 83520 is Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
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 code 83520. Our reviewer says that the medical 
records do not support the billing of code 83520. Our reviewer found the records submitted show that a 
calprotectin assay was performed. There is a more specific code for this test. 83520 is to be used when no code 
exists for the assay(s) performed. 
 
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 83520 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 83520 provided on October 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission 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 notes that the medical records show your ability to participate in intensive therapy was described as limited by the hospital physical therapist due to fatigue, impaired strength, coordination, and balance. Your spinal stenosis and right leg issues were to be followed up as an outpatient. You were using a walker at his baseline level of function.
The Plan is correct in this case. 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.
The rules state that you must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program at the time of admission. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The medical records provided do not show you met these criteria. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission 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 noted that Maximus did not address the medical records that stated the enrollee's ability to participate in intensive therapy was described as limited by the home health occupational therapist, given their poor endurance and history of progressive functional decline since surgery in June 2022.
The Plan is correct in this case. 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. Based on the medical records provided, at the time of the appeal there was no indication in the documentation that the enrollee would either benefit from or have the ability to participate in the type of intensive therapy provided in an IRF setting. Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for March 22, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone code. 
 
We looked at the file and Medicare rules. The file shows that ode 99153 has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission 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 noted that the medical records show at the time of the appeal, the enrollee was described as limited by the hospital physical therapist due to weakness, fatigue, pain, and need for rest breaks and help, even during a very short therapy session.
The Plan is correct in this case. 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. Enrollees must be able to participate in an intensive therapy program prior to entering the IRF facility. Based on the medical records provided, the enrollee did not meet the criteria needed for approval of this admission.
Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory antibiotic resistance polymerase chain 
reaction (PCR) panel (87486, 87798, 87496, 87498, 87502, 87532, 87451, 87581, 87640, 87651) provided on 
September 3, 2022. 
 
You asked the Plan to pay for the respiratory antibiotic resistance PCR panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing was not billed with a single panel 
code as required. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the respiratory antibiotic 
resistance PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory antibiotic resistance polymerase chain reaction (PCR) panel (87486, 87798, 87496, 87498, 87502, 
87532, 87451, 87581, 87640, 87651) provided on September 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220), and gingivectomy or gingivoplasty - one to three contiguous 
teeth or tooth bounded spaces per quadrant (D4211) provided on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are on a fixed income, and you cannot 
afford this bill. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4211 is not among 
those covered under this benefit. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered D0140 on 
March 16, 2022, and November 30, 2022, and received covered D4211 on November 30, 2022. Therefore, 
these benefits were exhausted as of November 30, 2022. Therefore, we decided that the Plan does not have to 
pay for limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image 
(D0220), and gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per 
quadrant (D4211) provided on November 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43281 billed for date of service April 11, 
2022. 
 You asked the Plan to pay for procedure code 43281. The Plan denied your request. The Plan says payment for 
code 43281 is bundled into payment for code 43774. 
 
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 43281 
is a column II code to column I code 43774. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 43281 billed for date of 
service April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for October 4, 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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
 
 
 
 
 We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for 
October 4, 2022.