Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 29, 2022, to 
November 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 29, 2022, to 
November 27, 2022.  
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding 
the submission of a corrected claim need to be sent to the Plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000) provided on August 23, 2021.  
 
You asked the Plan to pay for foot orthotics. You say that the orthotics at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics 
(L3000) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 units of code G0277 billed for date of service February 10, 
2023. 
 
You asked the Plan to pay for 4 units of code G0277. You say that this code was billed correctly. The total time 
allowed for a 90-minute treatment includes 10 minutes of descent, a 10 minute break, and 10 minutes of ascent. 
This total 120 minutes and therefore 4 units is appropriate. The Plan denied your request. The Plan says code 
G0277 (4 units) is not supported by the medical record. The records do not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0277 is Hyperbaric oxygen under pressure, full body 
chamber, per 30 minute interval. 
 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 4 units of code G0277. Our reviewer says that 4 units of code 
G0277 are not supported by the medical record. The record states that 90 minutes was spent performing this 
service. The number of units is based on the time documented in the record. Three 30-minute units are 
supported.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 units of code G0277 have not been met. Therefore, we decided that the Plan 
does not have to pay for 4 units of code G0277 billed for date of service February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care billed with code 99220 for 
October 4, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99220 was billed by a physician in the same group practice on the same day as code 99217. Code 99220 cannot be separately paid in this 
instance. Therefore, we decided that the Plan does not have to pay for the initial observation care billed with 
code 99220 for October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliances coded E0673 billed for November 14, 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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliances billed with code E0673 are also not covered. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (PCD) coded E0675 and half leg appliances coded E0673 billed for 
November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service January 11, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the treatment was medically necessary. The Plan 
denied your request. The Plan says the services are not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. A review of the file and Medicare records indicates that the referring provider is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for procedure code 99214 billed for date of 
service January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures. 
 
You asked the Plan to pre-approve the dental services. You say that you need a complete set of dentures. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 14, 2022. 
Therefore, we decided that the Plan does not have to pre-approve dentures.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is 
living at home with ongoing back pain after a recent kyphoplasty. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain the enrollee's functional status. The enrollee has been medically stable and 
is functioning mostly at a supervision/stand-by level of assistance. The enrollee can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positive airway pressure (PAP) machine supplies to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve PAP supplies. You say that you need these supplies. The Plan denied your 
request. The Plan says this supplier is out-of-network with the Plan and the needed supplies can be obtained in-
network. 
 
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 
positive airway pressure (PAP) machine supplies to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 27, 2022, 
to October 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 27, 2022, to 
October 26, 2022.  
 
Please note that this decision is limited to the Plans denial of your original claim.  Any questions regarding the 
submission of a corrected claim must be sent to the Plan directly.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee has been on a brace with no relief. 
The Plan denied your request. The Plan says the enrollee has multilevel disc disease in the lower thoracic spine. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery may be covered if certain 
criteria are met. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this surgery. Our physician reviewer found there is magnetic resonance 
imaging (MRI) corroboration of multiple other plausible causes of the enrollee's back pain. Therefore, the 
enrollee has a contraindication to this surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy (Rezum) (53854). 
 
You asked the Plan to pre-approve the Rezum procedure. You say that this procedure is approved by the Food 
and Drug Administration (FDA). The Plan denied your request. The Plan says this service 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 Rezum procedure. Our reviewer 
says that the requested Rezum procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is indicated for symptomatic males with BPH that have a prostate 
volume of 30 to 80 milliliters (mL). The provided documentation indicates that the prostate volume in this case is 101 mL. Therefore, the reviewer found that the requested Rezum procedure is not medically reasonable or 
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 Rezum procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transurethral destruction of prostate tissue; by radiofrequency generated water 
vapor thermotherapy (Rezum) (53854).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 3,
2022, coded as 63709.
You asked the Plan to pay this claim. You say that this service should be paid. The Plan denied your request.
The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating these
codes can be billed as is. The Plan requested a reopen and noted that the Plan did not deny payment due to a
PTP edit. The Plan notes code 63710 is included within the global surgery package of procedure code 63709.
Code 63709 has a global day period of 90 days and was billed on the same date as 63710. The provider did not
use the request 78 modifier as required by Medicare. The guidelines stated "when treatment for complications
requires a return trip to the operating room, physicians must bill the code that describes the procedure(s)
performed during the return trip.
If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated."
The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circumstance may be reported by adding the modifier "-78" to the related procedure. Per the above Medicare guidelines, the Plan has correctly denied the claim for payment as the provider did not bill an appropriate modifier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code and when necessary, with the appropriate modifier. In this case, this claim could not be paid as billed due to the omission of a 78 modifier. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 3, 2022, coded as 63709.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 14, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27447 billed for date of service February 1, 
2023. 
 
You asked the Plan to pay for procedure code 27447. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment 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, the CPT Code Manual definition of code 27447 is: Arthroplasty, knee, condyle and plateau; medial 
AND lateral compartments with or without patella resurfacing (total knee arthroplasty). 
 
We find that CPT code 27447 is not supported in the medical record. Specifically, no operative report has been 
provided to the Plan. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Based on this information, we decided that Medicare rules for coverage of procedure code 27447 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27447 billed for date of service February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral feeding supply allowances (B4035) provided 
March 3, 2023. 
 
You asked the Plan to pay for the enteral feeding supply. You say that please resubmit this clam for payment. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the enteral feeding supply allowances (B4035) provided March 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BAROSTIM NEO device.  
 
You asked the Plan to pre-approve the BAROSTIM NEO device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the BAROSTIM NEO device. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this item is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the BAROSTIM NEO device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the BAROSTIM NEO device.