Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to pay for ambulance services described with codes A0427 and A0425. We 
decided that the Plan does not have to pay for ambulance services described with code A0999.  
 
You asked the Plan to pay for ambulance services provided on April 16, 2023. You say that these services were 
medically necessary. The Plan says that this claim was processed correctly, and code A0999 is not payable per 
Medicare rules. 
 
We decided that the Plan has to waive the coinsurance for ambulance services described with codes 
A0427 and A0425.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 for each covered, one-way ambulance trip.  
 
The Plan says you must pay a coinsurance of $92.43 for the ambulance services. Based on the Plan contract, 
however, you cannot be asked to pay more than $0 for each covered, one-way ambulance trip. Therefore, we 
decided that the Plan has to waive the coinsurance for ambulance services described with codes A0427 and 
A0425.  
 
We also decided that the Plan does not have to pay for ambulance services described with code A0999. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance services described with code A0999 in the amount 
of $2.00. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214, 96366, 96521, and J1817 billed on 
March 1, 2023. 
 
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 codes 96366, 96521, and J1817 are 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 96366 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
procedure). The definition of code 96521 is refilling and maintenance of portable pump. The definition of code 
J1817 is insulin for administration through dme (i.e., insulin pump) per 50 units. 
 
We find that CPT codes 96366, 96521, and J1817 are not supported in the medical record. Specifically, the 
records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate code set for these services. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. 
 
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 99214 
is a column II code to column I code 96365. 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 codes 99214, 96366, 96521, and J1817 
billed on March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Freestyle Libre 2 continuous glucose
monitor (CGM) for the enrollee.
You asked the Plan to provide coverage for a Freestyle Libre 2 continuous glucose monitor (CGM) for the
enrollee. You say that at the time of the appeal, the requested device was medically necessary. The Plan denied
your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial
for insufficient medical records. The Plan requested a reopen and provided the required medical records.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan. Based on the medical records provided, the enrollee was not being treated with insulin at the time of the
request. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to provide
coverage for a Freestyle Libre 2 continuous glucose monitor (CGM) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission into a long term acute care 
hospital is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care in their current facility. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. The requested LTACH services are not medically necessary.  
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) and segmental pneumatic appliance for use with pneumatic compressor, 
full arm (E0668) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and full arm segmental pneumatic appliance to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 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 
a pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor, full arm (E0668) to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3. You say that the medical records support the need for 
the FreeStyle Libre 3. The Plan denied your request. The Plan says coverage for the CGM has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre 3. Our reviewer 
says that the FreeStyle Libre 3 is not medically necessary. Our physician reviewer found the provided medical 
records do not clearly document that you are insulin treated. An order for the CGM states you are injecting 
insulin four times daily but the medical documents themselves do not support this. The only documented active 
diabetes medication in the medical note is Ozempic. The provided records in this case do not document a 
history of problematic hypoglycemia. 
 
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 FreeStyle Libre 3 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Libre 3.
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 enrollee would not be safe to discharge to home 
and was independent prior to hospitalization. The Plan denied your request. The Plan says the enrollee's records 
do not show the need for an intensive team for care. The Plan says that the services needed may be provided 
safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 enrollee would benefit from short term IRF 
rehabilitation to improve functional mobility, ADLs, and gait to reduce caregiver burden and acute care 
hospital readmission. The Plan denied your request. The Plan says the enrollee's records show that it is not 
reasonable to expect to be able to fully benefit from the intensity of services of an IRF. The Plan says that the 
services needed may be provided safely in a lower level of care. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria
were not met. Maximus overturned the Plans denial. After the decision was made an error was found and the
case was reopened and reviewed by our Medical Director.
Our Medical director stated that at issue is coverage for IRF services. The enrollee was a then 74-year-old
woman who was admitted to the hospital on July 28, 2023, with a left periprosthetic femur fracture and a right
rib fracture following a fall. The past medical history was notable for hypertension, stage 2 chronic kidney
disease, normocytic anemia, rheumatoid arthritis, and bilateral knee replacements. Orthopedics was consulted,
and the enrollee underwent hardware removal from the left distal femur, and "ORIF" of the left femur. The
enrollee required hands-on assistance for daily activities, bed mobility, and transfers. She was ambulating short
distances with hands-on assistance. It was determined that the enrollee presented as a high fall risk due to her
anxiety and fear of falling. She would benefit from continued skilled therapy to improve functional
independence.
Based on the medical records provide, the enrollee does not have documented complex daily skilled nursing
needs. The records do not support the need for daily therapy in an acute hospital inpatient setting with an
interdisciplinary approach to rehabilitation care. There is insufficient documentation supporting that the
enrollee required at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy
services. Medicare coverage criteria were not met.
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 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 laboratory services rendered on August 24, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the craniectomy or craniotomy for evacuation of hematoma, 
supratentorial; extradural or subdural (61312-50) provided on January 13, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the file shows that when 
billing for a bilateral surgery and the procedure is not identified by its terminology as a bilateral procedure (or 
unilateral), physicians must report the procedure with modifier -50. and report such procedures as a single 
line item. Therefore, as procedure code 61312 is not identified by its terminology as a bilateral procedure and 
modifier -50 was billed on a second line item for the same procedure, we find the Medicare rule for 
reimbursement of code 61312-50, on this January 13, 2023, inpatient claim has not been met. Therefore, we 
decided that the Plan does not have to pay for the craniectomy or craniotomy for evacuation of hematoma, 
supratentorial; extradural or subdural (61312-50) provided on January 13, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 70350, 70355, 76100, and 99203 rendered on 
November 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the 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 
the denied codes is: 
 
CPT 70350: 
 
Cephalogram, orthodontic 
 
CPT 70355: 
 
Orthopantogram (eg, panoramic x-ray) 
 
CPT 76100: 
 
Radiologic examination, single plane body section (eg, tomography), other than with urography 
 
CPT 99203: 
 
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically 
appropriate history and/or examination and low level of medical decision making. When using time for code 
selection, 30-44 minutes of total time is spent on the date of the encounter 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that there are several addenda which have 
been noted in the submitted records of the care rendered on November 9, 2022. There is a written report of the 
cephalogram (CPT 70350) in the records, as well as documentation and interpretation of the Panorex view 
(CPT 70355). There are images of the temporomandibular joints in the records, including a report, therefore 
CPT 76100 is supported. The low-level initial visit of CPT 99203 is supported by the records and 
interpretations of the various exams and notes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 70350, 70355, 76100, and 99203 rendered on November 9, 2022.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eCoin stimulator device (64590). 
 
You asked the Plan to pre-approve an eCoin stimulator device. You say that you are requesting approval of 
eCoin therapy for this enrollee. The Plan denied your request. The Plan says this device is considered 
experimental and unproven as there is insufficient evidence of its safety and effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an eCoin stimulator device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an eCoin stimulator device (64590).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room evaluation and management visit
provided to the enrollee on September 6, 2022.
You asked the Plan to pay for the emergency room evaluation and management visit. You say that this code is
supported with a modifier indicating separate supporting diagnosis for this procedure. The Plan denied your
request. The Plan says that this service was not billed with the correct modifier. The Plan was correct in this
case. This claim needed to be billed with modifier 24 to show this service was received post operatively. Based
on this information, we decided that Medicare rules for coverage of the emergency room evaluation and
management visit have not been met. Therefore, we decided that the Plan does not have to pay for the
emergency room evaluation and management visit provided to the enrollee on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested electronic connection between wheelchair 
controller and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve the E2310 electronic connection. You say that the group 3 power chair is a 
better fit to meet the enrollee's postural support, comfort, functional and mobility needs for them to 
independently and safely navigate through environments throughout their day. The Plan denied your request. The Plan says management of power feature using a single joystick controller, rather than through its own 
switch is not reasonable and necessary in this enrollee's scenario. 
 
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 E2310 electronic connection. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has sufficient strength and function in upper extremities to manage 
standard power drives using their individual switches. Control from the main drive control is not medically 
necessary. 
 
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 E2310 electronic connection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the requested electronic connection between wheelchair controller and 
one power seating system motor (E2310).