Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the gynecology visit. We decided that the Plan does not have to reduce 
the copayment for this visit to $5.  
 
You asked the Plan to pay for the gynecology visit (99387) provided on August 3, 2023. You say that you were 
referred to visit this doctor for the first time, as your primary doctor was unable to help you with your 
symptoms. You feel this claim should be paid and you should owe only a $5 copayment for a primary care visit 
with a gynecologist. The Plan says that you have already exhausted your benefit for a preventative cervical and 
vaginal cancer screening. 
 
We decided that the Plan has to pay for the gynecology visit.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that this service is denied as you have already 
had your preventative cervical and vaginal cancer screening within the benefit period. However, the service at 
issue is an initial office visit with a new patient. The Plan even states that code 99387 is not listed on the 
Medicare preventative service list. This office visit is not a screening, and the records provided indicate that no 
additional screenings were performed at this time, but a specific problem was discussed. Therefore, we decided 
that the Plan has to pay for the gynecology visit.  
 
We also decided that the Plan does not have to reduce the copayment to $5. 
 
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 an office visit with an in-network specialist. The records provided indicate that you had a 
previous annual visit with your primary care gynecologist on June 8, 2023. This means that you had used your 
annual visit for 2023 already at the time of services. In addition, this visit was provided with a new provider to 
discuss a specific problem. This means the service at issue would be considered a specialist visit rather than an 
annual physical. Therefore, we decided that the Plan does not have to reduce the copayment for this visit to $5, 
as your contract with the Plan requires a $35 copayment for a specialist office visit. 
 
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 provide coverage for a skin substitute application (Q4229).

You asked the Plan to provide coverage for a skin substitute. You say that at the time of the appeal, this
treatment was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria
were not met. Maximus overturned the Plans denial. The Plan stated that Maximus did not apply the correct
criteria. The Plan noted that the medical records show a right foot surgical wound due to bunion surgery and
"excision of cyst right hallux." The medical records show measurements of a residual right hallux nail bed
wound, described as having a "healthy granular base." An additional set of measurements of the "right hallux
incision and nail bed" are noted 13 days later, with notation of "new wound dehiscence at the MPJ." The
records show the wound was a non-pressure chronic non-healing wound. You are not a diabetic. The Maximus
reviewer did not consider that this request was based on wound measurements over an only 13-day period. In
addition, the request is for an amniotic product for this nail bed surgical wound; amniotic products are only
Food and Drug Administration (FDA) approved for diabetic foot wounds and venous wounds, neither of which
is the reason or origin for the wound being treated.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for skin substitute application.

Medicare requires a specific diagnosis and failure to respond to appropriate control of infection, foreign body,
tumor resection, or other disease process for a period of 4 weeks or longer. Based on the medical records, the
wound was 13 days old, and the wound was result of a surgical procedure and not diabetic or venous wounds.
Therefore, we decided that the Plan does not have to provide coverage for a skin substitute application
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on July 21, 2023. 
 
You asked the Plan to pay for outpatient surgery. You say that you are requesting reconsideration for the 
denied claim. 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 outpatient surgery 
provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00120 for date of service September 30, 
2022. 
 
You asked the Plan to pay for procedure code 00120. You say that you disagree with the Plans denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that S32.811A (Multiple fractures of pelvis with unstable disruption of 
pelvic ring, initial encounter for closed fracture) has an Excludes1 note in relation to S32.502A (Unspecified 
fracture of left pubis, initial encounter for closed fracture). This means that the two diagnosis codes cannot be 
reported together. Based on this information, we decided that the Medicare billing rules for procedure code 
00120 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 00120 
for date of service September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1852) suspension sleeve (L2397) 
provided May 8, 2023. 
 
You asked the Plan to pay for the orthosis and accessory. You say that please see attached medical records. The 
Plan denied your request. The Plan says based on the records there is no evidence to support that this knee 
brace is reasonable and 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 pay for the orthosis and accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has not had recent surgery or a recent injury. The documentation does 
not support that the joint is unstable or that there is joint laxity. The requested knee orthosis is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the orthosis and accessory have not been met. Therefore, we decided that the 
Plan does not have to pay for the knee orthosis (L1852) suspension sleeve (L2397) provided May 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service June 15, 
2023, to July 13, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the provider did 
not bill are required by coding regulations. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The claim shows the first date of service as June 26, 2023. The Q code was 
billed for date of service June 28, 2023. The Q code must be submitted with the date of the first visit reported 
on the claim. 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 the home health care billed for 
dates of service June 15, 2023, to July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 6, 2023, billed with 
evaluation and management (EM) code 99204. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the level of care 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level or that at least 
45 minutes were spent. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 6, 2023, billed with evaluation and 
management (EM) code 99204.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service April 17, 
2022.  
 
You asked the Plan to pay for procedure code 99233. You say that the critical care services were separate from 
the multiple procedures provided. The Plan denied your request. The Plan says payment for code 99233 is 
bundled into payment for code 00790. 
 
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 99233 is a column two code to column one code 00790 with a 
modifier indicator of 0. The column two 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 
99233 billed for date of service April 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 6, 2023, billed with 
procedure code 99205. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code M41.56, described 
as other secondary scoliosis, lumbar region. This code is not an appropriate primary diagnosis as the code has a 
code first note indicating to code the underlying condition first. Based on this information, we decided that 
Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have 
to pay for practitioner services provided on June 6, 2023, billed with procedure code 99205.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the CardioMEMS device at this point 
should only be approved for patients enrolled in a clinical trial. There is no indication that this enrollee is 
enrolled in a clinical trial of the device. The Plan denied your request. The Plan says this device is 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 23, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 87653-XU and 87481 billed to the enrollee
for December 16, 2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating
the medical records support the services were performed. The Plan requested a reopen and stated the issue was
not whether the services were performed but how they were billed. The Plan noted that the lab results indicate a
urinary tract infection (UTI) panel was requested and performed. This test would be considered a molecular
syndromic panel for infectious disease pathogen identification testing. Per Local Coverage Article (LCA)
A58761, group 8 codes would be non-covered on the same day if billed in combination with another CPT or
PLA code from groups 1-7 for the same intended use. Codes 87653 and 87481 both all under the group 8 codes
list. Since code 87801 is listed under the group 5 (urogenital/anogenital panels) codes 87653 and 87481 would
not be reimbursable with code 87801. Additionally, per LCA A59020, the test panel is a single test with
multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled
and billed as individual components although the test reports multiple individual pathogens and/or targets.

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 codes.

In this case, these codes cannot be billed separately based on the Medicare billing guidelines for this type of
testing. Based on this information, we decided that Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87653-XU and 87481 billed
to the enrollee for December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2023. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service May 24, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of treatment. The 
Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is not supported in the medical record. Code J3490 was billed for local anesthetic drug Bupivacaine. The use of 
local anesthesia is not separately billable. 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 J3490 billed for date of service May 24, 2023.
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 and the enrollee 
has no one at home to help with their care needs. The Plan denied your request. The Plan says the enrollee does 
not meet the 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 treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service July 5, 2023.   
You asked the Plan to pay for procedure code 88341. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed number of units are not supported by the records as both provided and 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE.  
 
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 88341. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found the records include the 
anatomical pathology supplemental surgical report, but no justification for the additional units of CPT 88341 is 
documented.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 88341 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88341 billed for date of service July 5, 2023.