Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on November 24, 2022, 
billed with codes 99291 and 99223-25. 
 
You asked the Plan to pay for inpatient hospital care provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 99291 and 99223-25 is Critical care, evaluation and 
management of the critically ill or critically injured patient; first 30-74 minutes, and Initial hospital care, per 
day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive 
history; A comprehensive examination; and Medical decision making of high 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 high severity. Typically, 70 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 inpatient hospital care provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the record does not support that the 
services were performed by the billing provider as 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 inpatient hospital care provided have not been met. Therefore, we decided that 
the Plan does not have to pay for inpatient hospital care provided on November 24, 2022, billed with codes 
99291 and 99223-25.
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 services are medically necessary.  The Plan 
denied your request. The Plan says the enrollee can reasonably be expected to continue their recovery at a 
lower level of care with good success.  
 
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 enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
You asked the Plan to pre-approve a complete mandibular denture. You say that you need your dentures replaced due to them being broken. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided the 2022 Evidence of Coverage.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 August 15, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided from October 10, 2022, to 
November 21, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for mental health services. You say that these services were provided by a 
credentialed provider. The Plan denied your request. The Plan says these services were 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 mental health services provided from October 10, 
2022, to November 21, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you have vision problems. The Plan 
denied your request. The Plan says your routine transportation benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bitewings - four radiographic images (D0274) for the enrollee.
You asked the Plan to pre-approve the bitewings. You say that it is necessary for the enrollee to have this x-ray. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided Explanation of Benefits for these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 July 25, 2022. Therefore, we decided that the Plan does not have to pre-approve bitewings - four radiographic images (D0274) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on January 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not have to pay because you refused the ambulance transport. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
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 January 18, 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 ambulance response and treatment with no 
transport provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns on teeth #7, 8, 9, 10, and 11 (D2740).
You asked the Plan to pre-approve the crowns. You say that the requested crowns were previously authorized with another provider. 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 Plan's 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 August 10, 2021. Therefore, we decided that the Plan does not have to pre-approve crowns on teeth #7, 8, 9, 10, and 11 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 You asked the Plan to pre-approve a power seat elevation system. You say that the requested elevation system 
is medically necessary. The Plan denied your request. The Plan says that a power seat elevation system is not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code remains 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status. We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate 
the presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99152 billed for date of service October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), an intraoral - periapical each additional radiographic image (D0230), core buildup (D2950) for teeth numbers 8, 10, 11 and 12, a porcelain/ceramic crown (D2740) for teeth numbers 6, 7, 11, 12, and 13, and a porcelain/ceramic retainer crown (D6740) for tooth number 8 provided on July 29, 2022.
You asked the Plan to pay for the dental services. You say that you fell, knocked out your teeth and received 18 stitches to your chin.
You also say that because of the damage this accident caused to your mouth, chin and teeth, you are having to have a significant amount of dental work performed. 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, coverage for codes D2950, D2740 and D6740 is limited to twice per calendar year and coverage for D0220 and D0230 are limited to once procedure per calendar year. The record shows your benefit for the requested services was exhausted before the date of service in dispute. Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), an intraoral - periapical each additional radiographic image (D0230), core buildup (D2950) for teeth numbers 8, 10, 11 and 12, a porcelain/ceramic crown (D2740) for teeth numbers 6, 7, 11, 12, and 13, and a porcelain/ceramic retainer crown (D6740) for tooth number 8 provided on July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 12011-59 billed for date of service July 30, 2022. 
 
You asked the Plan to pay for code 12011-59. You say that the patient went into the emergency room for this 
medically necessary procedure. The Plan denied your request. The Plan says code 12011-59 is included in code 
21400. The medical records do not support that this service was distinct or independent from other services 
performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 12011-59 Our reviewer says that the 
use of the 59 modifier to allow for separate payment of code 12011 is not supported by the medical record. Our 
physician reviewer found the procedure report describes a closed fracture treatment and sutures of the right orbit.  In this case, a simple repair would be included in the fracture treatment, as both services were performed 
at the same anatomical location.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 12011-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 12011-59 billed for date of service July 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that Opdivo is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says Opdivo has been prescribed for an off-label, not medically accepted 
use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Opdivo is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia nor by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Opdivo (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 10060-59 and 20611-59-LT billed for date of service 
August 30, 2022. 
 
You asked the Plan to pay for codes 10060-59 and 20611-59-LT. You say that the medical records support 
payment of these codes. The Plan denied your request. The Plan says codes 10060-59 and 20611-59-LT are not 
separately payable. Code 10160-59 cannot be paid because the documentation doesn't support the 
comprehensive code of 20611, this component code cannot be paid. For code 20611-59-LT, the records do not 
indicate that arthrocentesis, aspiration and/or injection, major joint or bursa, with ultrasound guidance, with 
permanent recording and reporting was performed. 
 
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 20611 is Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 
 
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 codes 10060-59 and 20611-59-LT. Our reviewer says that 
codes 10060-59 and 20611-59-LT are not separately payable. Our reviewer found for code 10160, this 
procedure includes an edit with code 20611.  When service reported correctly, code 10160 would be included 
with the arthrocentesis procedure. For code 20611, the procedure report documents, "In a prone position, we 
prepped the posterior left knee with Chlorhexidine swab.  I visualized a 20-guage needle enter within and 
aspirated 9 cc clear fluid.  I then placed the patient supine, prepped the superior lateral left knee, visualized a 
20-guage needle enter within and aspirated 8 cc of clear fluid, injected 1 cc Kenalog".  The documentation does 
not support 20611 per CPT code description "with ultrasound guidance", and therefore this procedure cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 10060-59 and 20611-59-LT have not been met. Therefore, we decided 
that the Plan does not have to pay for codes 10060-59 and 20611-59-LT billed for date of service August 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, full arm (K1025). 
 
You asked the Plan to pre-approve a non-pneumatic compression device and garment. You say that the 
requested device provides value, better care, and higher levels of compliance to the enrollee with treatment 
protocol that leads to improved outcomes. The Plan denied your request. The Plan says the requested device is 
currently considered to be experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-pneumatic compression device have not been met. Specifically, the requested device is 
considered experimental and investigational and therefore, not a covered benefit with your Plan. Therefore, we 
decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, full arm (K1025).
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 services are medically necessary.  The Plan 
denied your request. The Plan says the enrollee does not meet the medical criteria for admission to an IRF.  
 
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 enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. 
The enrollee's care needs can be met 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 2, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. 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 nursing facility care provided on August 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on November 24, 2021. 
 You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 18, 2021. The services in question were provided 
before the end of that month.  Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care provided on November 24, 2021.