Persius/hicric huggingface dataset:
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 other levels of care will not accept the 
enrollee in their current medical state. The Plan denied your request. The Plan says they will continue to cover 
medically necessary acute and critical care at the current facility until the enrollee's condition is stable for 
transfer to an alternate level of care (such as a skilled nursing facility), or until the clinical circumstances 
change such that LTACH may be reconsidered. 
 
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 in this case the enrollee was admitted with septic shock secondary to diverticular abscess. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transport provided on May 27, 2023. 
 
You asked the Plan to pay for air ambulance transport. You say that the enrollee fractured multiple bones and 
air ambulance transport was necessary. The Plan denied your request. The Plan says the air ambulance 
transport was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport. Our reviewer says 
that the air ambulance transport was not medically necessary. Our physician reviewer found the enrollee had 
orthopedic injuries and the sending hospital reportedly has orthopedic services. Additionally, fractures of the 
humerus are often times managed conservatively. The transfer itself does not appear medically 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 air ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for air ambulance transport provided on May 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212-25 billed for date of service March 5, 
2020. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says payment for code 
99212 is bundled into payment with code 97597. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99212-25 is not supported in the medical record. Code 99212 was billed with minor 
procedure code 97597. The records do not show that code 99212 was a separate and distinct service. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99212-25 billed for date of service March 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99070, 11042 and 99309 billed for date of 
service August 2, 2023. 
 
You asked the Plan to pay for procedure codes 99070, 11042 and 99309. You say that the services at issue 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says the number of units 
billed of codes 11042 and 99309 exceeds the maximum allowed. Procedure code 99070 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. The rules also say that providers must report 
services correctly. Providers must report services with the appropriate procedure code. 
 
In this case, the MUE values for CPT codes 11042 and 99309 are 1. The MAI values for these codes are 2. You 
billed 2 units of each of these codes, exceeding the MUEs. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 11042 and 99309 have not been met. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met.  
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99070, 11042 and 99309 billed 
for date of service August 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF services as he cannot care 
for himself. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an 
SNF admission. 
 
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 the enrollee does not require the level of observation and treatment provided in 
terms of physician oversight and skilled nursing care. The enrollee is medically stable and is tolerating oral 
medications. He has not had an acute change in his neurological status and has impaired cognition at baseline. 
The enrollee does not require daily skilled nursing services; he requires primarily supervision for safely and 
mobility, and assistance for performing daily activities. The enrollee does not require the intensity of skilled 
therapy services in the SNF setting. Therefore, the SNF admission 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says Medicare does not cover naturopathic services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for an office visit provided on April 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee cannot have services done at home and 
not being admitted to an SNF is jeopardizing her life and health. The Plan denied your request. The Plan says 
criteria for admission has not been met. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 21, 2022, billed with 
procedure code 01992. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is not billed with an appropriate 
diagnosis code. 
 The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill Medicare for services 
that are not covered (as described by the entire LCD) as if they are covered. 
 
We looked at the file and Medicare rules. The claim has not been billed with an appropriate diagnosis from the 
list of diagnoses that support medical necessity. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on July 21, 2022, billed with procedure code 01992.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95939-TC, 95938-TC, 95861-TC, 95868-
TC, 95937-TC, and 95940 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code(s) 95939-TC, 95938-TC, 95861-TC, 95868-TC, 95937-TC, and 
95940. You say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan 
says these codes are included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that these services were provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95939-TC, 95938-TC, 
95861-TC, 95868-TC, 95937-TC, and 95940. This means there is both a professional and technical component 
for the CPT code(s). In this case, an appropriate modifier to indicate the professional component has not been 
billed with CPT code(s) 95939-TC, 95938-TC, 95861-TC, 95868-TC, 95937-TC, and 95940. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 95939-TC, 95938-TC, 95861-TC, 
95868-TC, 95937-TC, and 95940 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code(s) 95939-TC, 95938-TC, 95861-TC, 95868-TC, 95937-TC, and 95940 billed for date of 
service May 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
August 30, 2023. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that the enrollee became 
unresponsive and an ambulance was called. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $325 copayment for each out-of-network one-way ambulance trip.  
 
The enrollee has been asked to pay $325 copayment for ambulance transportation. This item/service falls 
within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on August 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
from September 24, 2023, to September 25, 2023. 
 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 the billed code is not substantiated by the clinical 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered from September 24, 2023, to 
September 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the capsulectomy or capsulotomy; interphalangeal joint, each
joint (26525-XS, F9) provided to the enrollee on January 20, 2023.

You asked the Plan to pay for these services. You say that this should be paid for. The Plan denied your
request. The Plan says that this service is not supported. Maximus overturned the Plan's denial. The Plan
requested a reopening and stated that we did not apply the correct criteria. The Plan is correct in this case.
Medicare rules say that providers must report services correctly. Providers must report services with the
appropriate CPT code. We find that CPT code 26525-XS, F9 is not supported in the medical record.
Specifically, the modifier F9 was appended to this claim incorrectly. The modifier F9 is an anatomical modifier
that represents the fifth digit of the right hand. The records do not show a capsulectomy or capsulotomy;
interphalangeal joint, each joint was performed on the fifth digit of the right hand. These services were
performed on the third and fourth digit of the right hand and the appropriate modifiers would have been F7 and
F8. 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 the capsulectomy or capsulotomy;
interphalangeal joint, each joint (26525-XS, F9) provided to the enrollee on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre kit 2 sensor.  
You asked the Plan to pre-approve the FreeStyle Libre kit 2 sensor. You say that the medical records provided 
support the need for the requested FreeStyle Libre kit 2 sensor. The Plan denied your request. The Plan says a 
CGM is not covered under Medicare if the member is not on insulin, or does not have documentation of 
recurrent problematic hypoglycemia. 
 
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 kit 2 sensor. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found coverage criteria for 
CGM require insulin use or low blood glucose sugar. The enrollee is not on a medication that typically causes 
low blood glucose sugar and we are not told of any low blood glucose sugar. Hence, although the CGM may 
help the enrollee adjust diet and control low blood glucose sugar, coverage criteria for CGM are 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 the FreeStyle Libre kit 2 sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre kit 2 sensor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the an ambulance response without transport provided on 
October 30, 2023. 
 
You asked the Plan to pay for the ambulance response. You say that you live alone and became concerned you 
would pass out, so you called the ambulance. After you received an electrocardiogram your heart rate went 
back down so you declined ambulance transport.  The Plan denied your request. The Plan says ambulance 
services are only payable when you are transported to a hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 30, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the an ambulance response without transport 
provided on October 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the intracept procedure is 
not medically necessary. 
 
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 intracept procedure. Our reviewer 
says that the intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease, and 
the cause of pain is not clear. 
 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
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 the enrollee needs to be transferred to an 
LTACH versus a lower level of care as their condition has stabilized and they will require a multi-disciplinary 
approach for an extended period. The Plan denied your request. The Plan says ongoing needs for skilled 
therapy, respiratory therapy, and skilled nursing may be completed in a lower level of care such as an inpatient 
rehabilitation facility (IRF) or a skilled nursing facility (SNF), as appropriate. 
 
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. At the time of the request 
for LTACH services, the enrollee is now on room air. The review has determined that the enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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.