Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that the requested drug is medically necessary for your 
ulcerative colitis treatment. The Plan denied your request. The Plan says that the requested drug has not met the 
step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Entyvio. Our reviewer says that the 
requested drug meets the requirement criteria for approval. Our physician reviewer found based on the 
documentation provided, you have failed formulary medications with mesalamine, humira and rinvoq and other 
medications in these classes (e.g., remicade) would not be recommended given your past failure. Therefore, 
Entyvio is 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 Entyvio have been met. Therefore, we decided that the Plan has to pre-approve 
Entyvio. 
  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on
January 17, 2023, and February 14, 2023.
You asked the Plan to waive the copayments for the specialist office visits. You say that these should be
considered post-op appointments and have no 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 you were responsible for the copayments. The Plan is correct in this case. The Plan
submitted the Explanation of Benefits for both dates of services to confirm you were 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 $30
copayment for specialist office visits. You have been asked to pay a $30 copayment for each of the specialist
office visits. This item/service falls within the specialist office visits benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayments for the specialist office visits provided on January
17, 2023, and February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99316 billed for date of service March 27, 
2023.  
 
You asked the Plan to pay for procedure code 99316. You say that this code is billable and payable. The Plan 
denied your request. The Plan says payment for code 99316 is bundled into payment for code 99223-AI. 
 
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 99316 is a column II code to column I code 99223-AI with a modifier indicator of 0. The column II code is therefore 
not payable. 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 99316 billed for date of service March 27, 2023.
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 the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is 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. 
 
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 pay for the water circulating heat pad with pump (E0217) billed for 
dates of service March 7, 2023, to March 13, 2023. 
 
You asked the Plan to pay for code E0217. You say that this item is medically necessary based on medical 
literature. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that water circulating heat pads with pumps (code 
E0217) are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump (E0217) billed for dates of service March 7, 2023, to March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, 99232, and 99238 rendered from 
April 1, 2023, to April 4, 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 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 99223: 
 
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded 
 
CPT 99232: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded 
 
CPT 99238: 
 
Hospital inpatient or observation discharge day management; 30 minutes or less 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 not supported by the medical records. Our reviewer found the records do not support this level of 
coding. In terms of CPT 99223, the records in this case do not document 2 out of 3 of an extensive number of 
diagnoses or management options, an extensive amount and complexity of data reviewed and high risk of 
complication. Therefore, the records do not support medical decision making of high complexity. Additionally, 
the records do not document 75 minutes or more of time spent on the service. 
 
In terms of CPT 99232, the records do not document a medically appropriate history and examination. The 
records do not support medical decision making of moderate complexity, as the provided records in this case 
do not document 2 out of 3 of multiple diagnoses or management options, a moderate amount and complexity 
of data reviewed and moderate risk of complication. Finally, the records do not document that 35 minutes or 
more of time was spent on this service. 
 
In terms of CPT 99238, the provided records in this case do not document that 30 minutes or less of discharge 
day management was performed. 
 
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 procedure codes 99223, 99232, and 99238 rendered from April 1, 2023, to April 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 77067 billed for date of service January 23,
2023.
You asked the Plan to pay for procedure code 77067. You say that the claim is billed correctly and should be
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
Maximus partially overturned the Plan's denial. The Plan requested a reopening and confirmed they approved
payment for procedure code 77063.
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.
In this case, the MUE for CPT code 77067 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of
procedure code 77067 have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 77067 billed for date of service January 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service May 11, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 10061 
provided on May 7, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 for date of 
service May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are covered by 
Medicare. The Plan denied your request. The Plan says there is insufficient documentation to support the 
services billed. 
 
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 drug testing have been met. 
Specifically, the physician order is limited and does not specifically request definitive drug testing or clarify 
which drugs are requested for testing. Without this information, we cannot verify that the service at issue were 
requested by the enrollee's treating physician and were medically necessary. Therefore, we decided that the 
Plan does not have to pay for drug testing (G0482) billed for date of service April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 5, 
2023, to January 6, 2023. 
 You asked the Plan to pay for procedure code 99232. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 
99233. 
 
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 99232 
is a column II code to column I code 99233. 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 99232 billed for date of service January 5, 2023, 
to January 6, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Epifix. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records support that the requested 
Epifix is reasonable and medically necessary for the enrollee to avoid surgical procedures, including 
amputation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Epifix.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve left total shoulder arthroplasty surgery. 
 
You asked the Plan to pre-approve total shoulder arthroplasty. You say that this surgery is needed to improve 
the enrollee's health. The Plan denied your request. The Plan says that the records do not show a massive 
rotator cuff tear, rotator cuff deficient arthropathy, humerus fracture, or arthritis with posterior glenohumeral 
subluxation. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 total shoulder arthroplasty. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found in this clinical scenario with the failure of multiple conservative treatment 
modalities, this procedure is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total shoulder arthroplasty have been met. Therefore, we decided that the Plan 
has to pre-approve left total shoulder arthroplasty surgery.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service February 
17, 2023. 
 You asked the Plan to pay for procedure code 76705-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 76705-26 is bundled into payment for 
code 76775-26. 
 
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 
76705-26 is a column II code to column I code 76775-26. 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 76705-26 billed for date of service 
February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
January 24, 2023, through February 19, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on January 24, 2023, through February 19, 2023.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic 
obstructive pulmonary disease (COPD) and was hospitalized in August of 2023 with acute COPD exacerbation 
and pneumonia. Pulmonary function tests in 2016 showed a forced expiratory volume (FEV1) of 32 percent of 
predicted with combined restrictive and obstructive lung disease. There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. The records do not show that he has tried and failed bi-level positive airway 
pressure (BiPAP) therapy with average volume-assured pressure support (AVAPS). The criteria for coverage 
are not met and the home ventilator is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 23, 2022, to 
April 21, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. In addition, the NOA you submitted was invalid because it had an incorrect "from" date.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 22, 2022. The NOA was not received by the Plan until April 22, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 23, 2022, to April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on May 09, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that it is medically necessary. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on May 09, 2023.