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

 
We decided that the Plan does not have to pay for procedure code 99223 billed on 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 99223 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 99223 is initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
 
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 99223 
is not supported. Our reviewer found the submitted documentation lacks a history of present illness and review 
of systems. The medical decision making was not of high complexity. The records do not support the billing of 
code 99223. 
 
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 99223 billed on February 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2022, billed with 
codes 81406, 81404, 81405, 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported as billed. 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 
July 13, 2022, billed with codes 81406, 81404, 81405, 81321 and 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313), power 
seat elevation feature (E2300), and arm rest pouches (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics, power seat elevation feature, and arm rest 
pouches. The Plan denied your request. The Plan says that the enrollee can control the power options using the 
standard switches. The Plan also says that the power seat elevation feature and arm rest pouches are not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that the upgraded electronics are medically necessary 
when it is necessary for the enrollee to control the power options through the joystick. The rules also say that 
for equipment to be covered, it must primarily serve a medical purpose.   
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee has adequate 
upper extremity strength to manage the standard power drive controls. 
 
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 upgraded electronics have not been met. The power seat elevation feature 
and arm rest pouches do not serve a purpose that is primarily medical in nature. Therefore, we decided that the 
Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313), power seat elevation 
feature (E2300), and arm rest pouches (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any worsening pain or stable/improving pain with progression 
of the fracture and impact on activities of daily living. 
 
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 that detailed documentation is not evident regarding moderate to severe pain that has failed optimal non-
surgical management (with progression of vertebral body height loss or severe impact of vertebral compression 
fracture on daily functioning). Additionally, there are x-ray and magnetic resonance imaging (MRI) images 
suggesting plausible other causes of her low back pain. Moreover, the MRI demonstrated L2 with severe 
central and mild anterior and posterior body height loss, 22% and 15% anterior and posterior body height loss, 
and moderate-severe retropulsion of upper body. Therefore, the enrollee does not meet the criteria for this 
request. 
 
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 percutaneous vertebral augmentation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 (Q4158) and application of a 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 (15271). 
 
You asked the Plan to pre-approve Kerecis Omega3 and application of a skin substitute graft. 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 Chronic Wounds are defined as wounds that do not 
respond to standard wound treatment for at least a 30-day period during organized comprehensive conservative 
therapy. 
 
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 Kerecis Omega3 and application of a 
skin substitute graft. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the enrollee has a history of squamous cell carcinoma in situ (Bowen's disease) of the scalp. Her provider plans Mohs microsurgery to treat this in situ cancer. This cancer is described as having arisen within actinic 
keratoses on the scalp. The review indicates 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 Kerecis Omega3 and application of a skin substitute graft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Kerecis Omega3 (Q4158) and application of 
a 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 (15271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 11, 2022, billed with 
multiple codes including 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
May 11, 2022, billed with multiple codes including 81335.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 93308 billed for date of service 
October 5, 2021. 
 
You asked the Plan to pay for procedure codes 99291 and 93308. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 99291 is 
bundled into payment for code 92950. Additionally, the records do not support the billing of code 93308. 
 
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 99291 
is a column II code to column I code 92950. 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.  
 
Additionally, 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 for payment of procedure code 93308. In this case, the 
CPT Code Manual definition of code 93308 is Echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, follow-up or limited study. Our reviewer 
says that the medical records do not support the billing of code 93308. Our reviewer found the medical records 
do not support the use of procedure code 93308, where this test was ordered, the enrollee was deceased before 
the Echo was performed. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99291 and 93308 billed for date 
of service October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says that the requested items 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
uses a power wheelchair and is non-ambulatory. She is not at high risk for skin breakdown and has used a 
wheelchair and has had long term impairment without skin breakdown. The enrollee can transfer 
independently. The enrollee does not use a catheter and does not have spasticity. As the power wheelchair base 
is not medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominal binder described by code A4467. 
 
You asked the Plan to pre-approve these services. You say that you have a hernia that is worsening and causing 
pain. The Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that elastic or other fabric support garments described by 
code A4467 is denied as non-covered. 
 
We looked at the file and Medicare rules. The item at issue is an abdominal binder described by code A4467. 
This item is not covered by Medicare because it does not meet the definition of a rigid or semi-rigid brace. 
Therefore, we decided that the Plan does not have to pre-approve an abdominal binder described by code 
A4467.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85007 and 85008 billed for date of service 
September 1, 2022.  

You asked the Plan to pay for procedure codes 85007 and 85008. You say that the patient was in the nursing 
home and needed care, so this claim should be paid. The Plan denied your request. The Plan says payment for 
codes 85007 and 85008 is bundled into payment for codes 85008 and 85025. 
 
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 
85007 and 85008 are column II codes to column I codes 85008 and 85025 with a modifier indicator of 0. The 
column II codes are therefore not payable. 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 codes 85007 and 85008 billed 
for date of service September 1, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin (J9035). 
 You asked the Plan to pre-approve Avastin. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Avastin. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Avastin. Our reviewer says that the enrollee does not meet the coverage criteria for Avastin. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our physician reviewer also found that the requested service cannot be recommended.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin (J9035).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement procedures on the skin provided on September 
23, 2022. 
 
You asked the Plan to pay for debridement procedures on the skin. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement procedures 
on the skin provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), trifocal lens (V2300), photochromatic 
tint (V2744), anti-reflective coating (V2750), progressive lens (V2781), and polycarbonate or equal lens 
(V2784) provided on November 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyewear. You say that you have gone to this doctor before, had always paid 
out of pocket, and it was reimbursed. You also say that the provider moved to a different office, and you 
assumed it would be the same procedure. The Plan denied your request. The Plan says the claim denied 
appropriately based on the Evidence of Coverage because the provider is OON. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received by a participating provider. 
 
We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we 
decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the 
Plan does not have to pay for the frames (V2020), trifocal lens (V2300), photochromatic tint (V2744), anti-
reflective coating (V2750), progressive lens (V2781), and polycarbonate or equal lens (V2784) provided on 
November 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair and refitting of spectacles (92370), and fitting of 
spectacles (92341) provided on August 3, 2022. 
 
You asked the Plan to pay for the repair and refitting of spectacles and fitting of spectacles. You say that the 
services were medically necessary for the enrollee's condition. You also say that the services were rendered to 
the enrollee in good faith. The Plan denied your request. The Plan says eyeglasses and examinations for the 
purpose of prescribing, fitting, or changing eyeglasses, procedures performed during the course of any eye 
examination to determine the refractive state of the eyes are excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the repair and refitting of spectacles (92370), and fitting of 
spectacles (92341) provided on August 3, 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 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 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 that you were hospitalized after a fall resulting in a hip fracture. You have complex functional impairments but no conditions or nursing, medical, or rehabilitation needs that require an acute inpatient stay with a multi-disciplinary approach to your rehabilitation care. The records do not support that IRF care is reasonable or 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a new patient office visit billed to the enrollee under Claim A
for date of service May 11, 2022.
You asked the Plan to pay for services billed under Claim A. You say that this claim should be paid. The Plan
denied your request. The Plan says new patient services were previously billed by the same provider under
Claim B. Maximus overturned the Plans denial because the previously paid claim was not submitted in the case
file. The Plan requested a reopen and provided a copy of the paid claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. The records show the enrollee received a new patient office visit from the billing
provider on September 21st, 2021. Procedure code 99204 (Office or other outpatient visit for the evaluation
and management of a new patient) would not be eligible for billing a second time.
Therefore, we decided that the Plan does not have to pay for an office visit (99204 for new patient) billed to the
enrollee under claim number 50937696-00 (Claim A) for date of service May 11, 2022.