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

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99223 billed for date of service November 11, 2022, and code 99239 billed for date of service November 12, 
2022. 
 
You asked the Plan to pay for 99223 and 99239. You say that 99223 and 99239 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 99223 and 
99239 are denied because they are not supported in 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 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. 
 
The CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
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 99223. Our reviewer says that 99223 billed 
for November 11, 2022, is not supported in the medical record. Our reviewer found the enrollee is a 67-year-
old who was treated in the hospital for pneumonia and an uncomplicated urinary tract infection (UTI), for 
which they were treated with antibiotics. The provided documentation includes an appropriate history and 
examination for follow-up, but the documentation did not sufficiently support a high level of medical decision-
making or an encounter duration of 75 or more minutes, as required. The enrollee was stable medically, was 
without hypotension, was tolerating room air, and was without distress. The treatment plan was not complex 
for this community acquired pneumonia.  
 
We looked at this physicians review, the file, and Medicare rules. We also find that CPT code 99239 is not 
supported in the medical record. Specifically, the code definition is time-based, and the records submitted for 
review for date of service November 12, 2022, do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of 99223 and 
99239 have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management services described by code 99223 billed for date of service November 11, 2022, and code 99239 
billed for date of service November 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A0432 billed for date of service September 10, 2023. 
 
You asked the Plan to pay for code A0432. You say that emergency services are covered under the patient's 
policy.  This was an emergency ambulance transport. The Plan denied your request. The Plan says this code 
was billed incorrectly. 
 
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 A0432 is paramedic intercept, rural area, transport 
furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers.  
 
We find that CPT code A0432 is not supported in the medical record. Specifically, your appeal letter stated that 
the services in dispute involved emergency ambulance transport. However, you did not bill a transport mileage 
code.  The code you billed is a paramedic intercept code. Medicare only pays for ambulance services when a 
transport occurs and mileage is billed.  The medical records indicate that your organization did transport the 
patient.  However, you have failed to bill a valid mileage code for the transport itself. Based on this 
information, we decided that Medicare rules for coverage of code A0432 have not been met. Therefore, we 
decided that the Plan does not have to pay for code A0432 billed for date of service September 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to care for yourself and are home 
alone at this time. The Plan denied your request. The Plan says this request was denied as not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your past level of function was modified independent with mobility and self care 
tasks currently requiring supervision with activities of daily living and modified independent with mobility 
tasks without any further daily inpatient skilled therapy goals specified. The clinical documentation does not 
specify any daily skilled nursing needs (lymph edema care) thus the medical necessity for continued daily 
skilled services is not supported. As a practical matter, clinical documentation does not support the medical 
necessity of continued daily skilled services on an inpatient basis in a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each magnetic resonance imaging (MRI) 
provided on August 15, 2023. 
 
You asked the Plan to waive the copayment for each magnetic resonance imaging (MRI). You say that the cost 
share is wrong. 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 $100 
copayment for Outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $100 copayment for each magnetic resonance imaging (MRI). This item/service 
falls within the Outpatient diagnostic tests and therapeutic services andsupplies 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 each magnetic resonance imaging (MRI) provided on August 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for code 99239 (1 Unit) billed to the enrollee for August 4, 2022.

You asked the Plan to pay for this service. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan
requested a reopen and provided the required records. The Plan notes the records do not record the actual time
spent with the enrollee that would allow payment of this code.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment. The medical records submitted do not clearly document there was hospital
discharge day management of more than 30 minutes provided to the enrollee.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of this service have been met. Therefore,
we decided that the Plan does not have to pay for code 99239 (1 Unit) billed to the enrollee for August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (29125, 73110) provided on July 24, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
packaged and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged service is packaged into the 
payment for the service(s) with status indicator S, T, V and no separate payment is made for the STV-packaged 
service. STV-packaged services are assigned status indicator Q1. 
 
We looked at the file and Medicare rules. The billed codes in this case, 29125 and 73110, are assigned status 
indicator Q1 under Outpatient Prospective Payment System (OPPS). As such, these codes are considered to packaged and are not separately payable. 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 pay for the 
services (29125, 73110) provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on September 7, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on September 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on May 19, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M are non-covered for 
CxBladder testing. 
 
We looked at the file and Medicare rules. The requested CxBladder testing billed with code 0012M, is not 
covered per LCD L35396. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing 
provided on May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 84443, 85025, 84153, 80053, 83036, 
and 80061, billed for date of service April 18, 2023. 
 
You asked the Plan to pay for procedure codes 36415, 84443, 85025, 84153, 80053, 83036, and 80061. The 
Plan denied your request. The Plan says procedure codes 36415, 84443, 85025, 84153, 80053, 83036, and 
80061, are not payable to this specialty. 
 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 codes 36415, 84443, 85025, 84153, 80053, 83036, and 80061, have a status indicator of 
X on the Physician Fee Schedule. This means that procedure codes 36415, 84443, 85025, 84153, 80053, 
83036, and 80061, are not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 36415, 84443, 85025, 84153, 80053, 83036, and 80061, have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 36415, 84443, 85025, 84153, 
80053, 83036, and 80061, billed for date of service April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 subsequent nursing facility care provided on July 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health admission 
 
You asked the Plan to pre-approve the admission. You say that you would like to request reconsideration of the 
denied services and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the criteria for approval have not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that it was not 
expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not 
showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors 
while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question. The health plans denial of continued inpatient psychiatric services appears appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient behavioral health admission
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 16, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on June 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11046) provided on May 31, 2023. 
 
You asked the Plan to pay for code 11046. The Plan denied your request. The Plan says the add-on code was 
not billed with a primary code. 
 
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 11046 is an add-on code and has not been billed with an appropriate primary procedure code. 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 services (11046) provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on August 18, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M are non-covered for 
CxBladder testing. 
 
We looked at the file and Medicare rules. The requested CxBladder testing billed with code 0012M, is not 
covered per LCD L35396. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing 
provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation 
(97112), and the electrical stimulation (G0283) provided on September 5, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered by Medicare or 
the Plan.   
 
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.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation (97112), 
and the electrical stimulation (G0283) provided on September 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core buildup, 
including any pins when required (D2950) provided on September 18, 2023. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items provided are not covered 
under the supplemental dental policy.  
 
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 items provided are not among those 
covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core 
buildup, including any pins when required (D2950) provided on September 18, 2023.