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

We decided the Plan does not have to pay for code 76641 billed to the enrollee for date of service July 22, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided additional information. The Plan notes that per the Medically Unlikely Edit (MUE) Practitioner Services sheet Effective July 1, 2022, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2 indicating this is a date of service edit. The Plan states the MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022. As the date of service in question is July 22, 2022, the new MUE value of 1 would apply.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim could not be paid as billed due a change in the MUE value for code 76641. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 76641 billed to the enrollee for date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you wanted to see a specialist for you tremors. 
The Plan denied your request. The Plan says the plan does not cover out-of-network services rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on April 8, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided additional claim information. The Plan shows that Per Medicare NCCI Chapter I Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If a provider/supplier reports the 2 codes of an edit pair, the Column Two code is denied, and the Column One code is eligible for payment. However, if it is clinically appropriate to use an NCCI PTP associated modifier, both the Column One and Column Two codes are eligible for payment. (NCCI PTP-associated modifiers and their appropriate use are discussed elsewhere in this chapter.). Section E of this Chapter explains modifiers that with clinical circumstances the NCCI PTP edit can be by passed. Anatomic modifiers include E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, and RI. Global surgery modifiers include 24, 25, 57, 58, 78, and 79. Other modifiers include 27, 59, 91, XE, XS, XP, and XU. The non-participating provider is appealing the denial of procedure code 93971-26 (Dup Scan Veins unilateral) provided on April 8, 2022. The Plan is submitted proof that both claims have the same 26 professional component modifier and neither have any bypass modifier indicating repeat/separate/distinct service was performed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to the previously submitted claim for the same service. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on April 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from May 27, 2022, 
through June 8, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says self-administered drugs do not fall under 
Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from May 27, 2022, through June 8, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you have a trach and need more 
assistance medically and physically. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and your needs can be met in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The health plan has approved ongoing care in the current acute 
care setting.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the immune globulin injection provided on 
October 13, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you had already met your out-
of-pocket maximum The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare Part B drugs.  The records show that the out-of-pocket maximum was processed correctly, and you are responsible for this 
cost share amount. You have been asked to pay $199.95, which is less than the standard 20% coinsurance for 
the drug injection. This item/service falls within the Medicare Part B drugs benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the immune globulin injection provided on October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 06, 2022. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. 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 lab services provided on 
July 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on February 15, 
2023. 
 
You asked the Plan to pay for domiciliary or rest home visit. 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 domiciliary or rest home 
visit provided on February 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD procedure. You say that the enrollee is due for colonoscopy for 
history of polyps The Plan denied your request. The Plan says the records do not show that the enrollee meets 
the medically necessary 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 an EGD procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's multiple co-morbidities places them at unjustifiable risk of an add-on 
EGD in the absence of significant upper gastrointestinal (UGI) symptoms, off proton pump inhibitors (PPIs) 
therapy, or endoscopic histology that requires surveillance, such as gastric intestinal metaplasia or Barrett's esophagus. The EGD as requested for the enrollee is neither medically appropriate nor 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 an EGD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on October 08, 2022, 
to October 12, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were surprised when 
you received a bill for this amount. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per day for days 1-6 and a $0 copayment per day for days 7-90 for Medicare-covered services for 
inpatient hospital care. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other 
types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you are discharged is your last day. There were 4 days. 4 x $295 
= $1,180. Therefore, results in the total cost sharing amount of $1,180.  
 
You have been asked to pay a $295 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital stay on October 08, 2022, to October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (49329) provided on March 9, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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 49329 is Unlisted laparoscopy procedure. 
 
We find that CPT code 49329 is not supported in the medical record. Specifically, an operative repair of ventral 
hernia was performed. There is a more appropriate code for this service. Based on this information, we decided 
that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (49329) provided on March 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing care (99308) provided on October 24, 2022. 
 
You asked the Plan to pay for the skilled nursing care. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not support 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 99308 is not supported in the medical record. Specifically, this code shares a bundled 
relationship with code 99309 which was billed on the same date. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing care have not been met. Therefore, we decided that the Plan 
does not have to pay for skilled nursing care (99308) provided on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these supplies urgently. You 
say that you have had difficulties in the past with obtaining these supplies through your over-the-counter 
benefits and catalog. You also say that you cannot purchase them on your own as you have a very limited 
income. The Plan denied your request. The Plan says the requested supplies are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary for you 
to finish your intravenous antibiotics, undergo dialysis, and participate in physical therapy and occupational 
therapy. The Plan denied your request. The Plan says the requested LTACH admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that you require that are not available at the health care setting 
being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and 
able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 9, 2023, to January 13, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you paid the 
copayment for the emergency room and should be reimbursed that amount. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $298 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you must pay a $0 copayment per day for days 6-90. The records show the payment you made for the emergency room copayment has been applied to the 
copayment for your inpatient hospital stay. You have been asked to pay a $298 copayment per day for days 1-4 
of the inpatient hospital stay. This item/service falls within inpatient hospital care benefit category. You have 
not been charged for the day you were discharged. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital stay provided from January 9, 2023, to January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA DISC NP Allograft Injection (0627T). 
 
You asked the Plan to pre-approve a VIA DISC NP Allograft Injection. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 a VIA DISC NP Allograft Injection. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
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 VIA DISC NP Allograft Injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a VIA DISC NP Allograft Injection (0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233-GQ and 99232-GQ provided from 
December 17, 2022, to December 18, 2022. 
 You asked the Plan to pay for procedure codes 99233-GQ and 99232-GQ. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 99233 and 99232 are not supported in the medical record. Specifically, the codes were 
billed with the GQ modifier. The GQ modifier is only valid when used by providers in Alaska or Hawaii. The 
rendering provider was not in Alaska or Hawaii. 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 codes 99233-GQ and 99232-GQ provided from December 17, 2022, to December 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 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 billed services. Our reviewer found that 
this initial hospital care evaluation and management code requires a comprehensive history, a comprehensive 
examination and medical decision making of high complexity. The records supported that there was a 
comprehensive exam and medical decision making of high complexity. However, the records did not support 
that there was a comprehensive history. Therefore, the billed code is not supported.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99223 billed for date of service November 4, 2022.