Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from December 6, 
2021, through December 11, 2021 at the Diagnosis Related Group (DRG) 871 originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG 871 originally billed. You say that you 
are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says 
the clinical documentation does not support the diagnosis billed. This results in a reassignment from DRG 871 
billed to DRG 177. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.89 as defined by other specified 
sepsis. 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 inpatient hospital services at the DRG 
871 originally billed. Our reviewer says that the inpatient hospital care provided was not billed correctly. Our 
physician reviewer found that the enrollee was diagnosed with COVID-19 pneumonia with gastrointestinal 
symptoms. The provided records indicate that the enrollee only required low dose oxygen support and was 
given fluids, steroids, remdesivir, and antibiotics. Her lactic acid and procalcitonin were normal. Antibiotics 
were stopped due to no evidence of bacterial infection. There was insufficient evidence to indicate that the 
glascow coma scale (GCS) was low enough beyond baseline to suggest encephalopathy, nor was there an acute 
behavioral disturbance (ABD) to confirm significant hypoxia when her oxygen saturation level was normal. No 
other labs were provided showing signs or organ failure to suggest a dysregulated response to infection. Sepsis 
3 criteria was not met. Therefore, diagnosis code, A41.89 is not supported in the documentation and the most 
appropriate DRG would be 177 for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from December 6, 2021, through December 11, 2021 at the 
Diagnosis Related Group (DRG) 871 originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 
29, 2022 to December 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 29, 2022 to December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 9, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 9, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes we tested on the date of service in question. 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 drug testing services (G0483) provided on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that your life is in danger without this item. The 
Plan denied your request. The Plan says a home ventilator is not medically necessary. Your needs can be met 
with a bilevel positive airway pressure (BiPAP) device with average volume-assured pressure support 
(AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary for you. Our physician reviewer found the provided records in 
this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary 
disease. However, the provided records document that the home ventilator is being requested for use in 
intelligent volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by 
a BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. The provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. The provided 
records in this case do not provide adequate detailed information to meet Medicare criteria for coverage of a 
ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to lower the copayment for the chest x-ray provided on March 10, 2022.
You asked the Plan to lower the copayment for the chest x-ray. You say that you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
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 $150 copayment for X-rays performed in an Outpatient Hospital Facility.
You have been asked to pay a $75.13 copayment for the chest x-ray. This item/service falls within the X-rays performed in an Outpatient Hospital Facility benefit category. This means that you have been asked to pay less than the applicable copayment 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 lower the copayment for the chest x-ray provided on March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular computed tomography (CT) scan of the neck.
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no order from the physician.
Our Medical director looked at the case file and the reopen request. At issue is coverage of a vascular computed tomography (CT) scan of the neck. Our Medical Director states that the documentation does not sufficiently support that a vascular CT scan of the neck was medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that your condition does not meet criteria for coverage of a CT scan.
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve vascular computed tomography (CT) scan of the neck.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 1, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 supported. 
 
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. 
 
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 the laboratory services have been met. 
In this case, the records provided did not include a physician order or lab requisition for the billed test. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service December 5, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lower extremity study provided on August 29, 2022.
You asked the Plan to waive the copayment for the lower extremity study. You say that you should not be responsible to pay this. 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 $35 copayment for diagnostic tests and procedures at a specialist's office. You have been asked to pay a $35 copayment for the lower extremity study. This item/service falls within the diagnostic tests and procedures at a specialist's office 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. Please note, the Plan has already waived the cost share for the second lower extremity study provided on this same date of service and you are only being asked to pay one $35 copayment. Therefore, we decided that the Plan does not have to waive the copayment for the lower extremity study provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96374 billed for date of service October 4, 
2022. 
 You asked the Plan to pay for procedure code 96374. The Plan denied your request. The Plan says payment for 
code 96374 is bundled into payment for code 99152. 
 
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 96374 
is a column II code to column I code 99152. 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 code 96374 billed for date of service October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 26, 2022, billed with codes 
36222-50-59 and 36225-59-LT. 
 You asked the Plan to pay for the services as billed. You say that this was billed correctly.  The Plan denied 
your request. The Plan says the codes 36222 and 36225 are not appropriate.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 36222 and 36225 are column II codes to column I codes 36223 and 
36226, respectively; however, the Column II codes were billed with modifiers.  
 
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 as billed. Our reviewer says that the use of the 
modifier is not clinically appropriate to bypass the edits.  Our reviewer found CPT code 36222 is not supported 
as separately identifiable. The services listed in this code are part of CPT code 36223 and the more descriptive 
code should be reported. CPT code 36225 is not supported as separately identifiable. The components of this 
code are part of CPT code 36226 and should not be reported separately; only the most descriptive code should 
be reported. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided on October 26, 2022, billed with codes 36222-50-59 and 36225-
59-LT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 provided on November 28, 2022. 
 
You asked the Plan to pay for procedure code 99221. You say that the medical records support the billing of 
code 99221 provided on November 28, 2022.  The Plan denied your request. The Plan says the medical records 
do not support the billing of code 99221 provided on November 28, 2022.  
 
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 99221 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99221. Our reviewer says that the medical 
records do not support the billing of code 99221 provided on November 28, 2022.  Our reviewer found the 
review has determined that the medical records did not support a detailed or comprehensive history. The 
medical records supported a detailed or comprehensive examination and medical decision making that was 
straightforward or of low complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99221 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99221 provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for naturopath services provided on August 9, 2022, and November 8, 2022.
You asked the Plan to pay for naturopath services. You say that these services were covered in July by the Plan but were not covered in August or November and should be. The Plan denied your request. The Plan says the Plan contract is clear that naturopath services are not covered. Maximus upheld the Plans denial. You requested an ALJ hearing. The ALJ judge reviewing your case remanded the case back to Maximus stating all dates in question were not reviewed. Maximus reopened your case and found there was enough documentation in the case file to review the services for August 9, 2022.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The Plan contract states that naturopath services are not covered. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for naturopath services provided on August 9, 2022, and November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm. 
 
You asked the Plan to pre-approve Aduhelm. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Aduhelm. Our reviewer says that 
Aduhelm is not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia, there is no documentation that the Aduhelm at issue in this case 
meets all Medicare criteria. The drug is not being administered as part of an approved clinical trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to confirm chronic carbon dioxide (CO2) 
retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
Average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.