Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for codes 83789 and 80307 for date of service February 14, 
2022. 
 
You asked the Plan to pay for code 83789 and 80307. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 and 80307 have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable.  
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, only one drug test within the 
presumptive drug class and one drug test within the definitive drug class per date of service and per enrollee. 
The enrollee's claim history indicates presumptive service have been previously submitted by another provider 
for this date of service.  
 
Based on this information, we decided that Medicare rules for coverage of codes 83789 and 80307 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 83789 and 80307 for date of 
service February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
service are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in targeted tidal volume - volume assured pressure support (TTV-VAPS) 
mode with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device 
with average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document 
trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional speech therapy visits. 
 
You asked the Plan to pre-approve speech therapy visits. You say that the enrollee lost their ability to 
communicate, and it has become a stressful factor for them. You say that the enrollee needs to work with a 
therapist at least 2 times per week to maintain and improve their ability to talk. The Plan denied your request. 
The Plan says 8 additional speech therapy visits are not medically necessary  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 speech therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has made limited neurological recovery and 
has shown a modest response to skilled therapy. The enrollee may progress with continuing a home exercise 
program. Therefore, the enrollee does not require continued input from a daily skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of speech therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional speech therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310).  
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor. You say that this accessory is necessary. The Plan denied your request. The Plan says an 
electronic connection cannot be covered as it is not medically necessary to control the approved power option 
through the joystick (drive interface).  
 
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 an electronic connection between 
wheelchair controller and one power seating system motor. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records document that the enrollee has 3+/5 to 4/5 bilateral upper extremity strength with normal tone 
and range of motion, thus indicating adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. Thus, the electronic connection 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 an electronic connection between wheelchair controller and one power seating 
system motor have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (procedure code G0483) rendered on 
January 3, 2023. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not 
used in clinical management exceeds the needs of the enrollee. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the records show that multiple drug class tests were performed. However, the records do not show 
screening test results which are positive or inconsistent with prescription medications, dosing schedules, or 
history and expected results. The review has determined that the enrollee did not require 22+ drug classes 
tested. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive drug testing (procedure code G0483) rendered on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you are unable to take 
anti-inflammatories orally. You are also getting a total knee replacement on June 12, 2023, and a fluid 
circulating cold pad with pump is included in after care for surgery.  The Plan denied your request. The Plan 
says a fluid circulating cold pad is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Specifically, the requested item is not a 
covered benefit with Medicare or your Plan. Therefore, we decided that the Plan does not have to pre-approve a 
fluid circulating cold pad with pump (E0218).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections, 2 levels. 
 
You asked the Plan to pre-approve repeat ESIs. You say that the requested injections are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria of four weeks 
of pain duration with an inability to tolerate noninvasive conservative care. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESIs. Our reviewer says that the 
requested repeat ESIs are not medically necessary. Our physician reviewer found the provided documentation 
does not indicate the degree or duration of pain relief from the last ESI. The reviewer found that the documentation does not indicate the enrollee's current pain scale. Therefore, the reviewer found that repeat 
ESIs are 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 repeat ESIs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injections, 2 levels.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2022, to July 
24, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. 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 code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.0, described as 
Acute kidney failure with tubular necrosis. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the enrollee is a 48-year-old female who was treated in the 
hospital. She was diagnosed with cholecystitis and underwent cholecystectomy. Following fluids, the patient 
had a glomerular filtration rate >60, creatinine 0.5-0.8. There was no urine testing with casts or other signs of 
acute tubular necrosis to support that diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 21, 2022, to July 24, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for September 28, 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 procedure code 99497 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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation 
the face-to-face time spent providing advance care planning services. 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 code 99497 billed for September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 10, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that the provider treated the enrollee in good faith. 
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 nursing facility care 
provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 2, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to additional claims for code 71250-26-77 billed to the enrollee for date of service February 18, 2022.
You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met as this was a duplicate billing. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the medical records provided only support one chest scan. The provider first billed code 71250-26 on February 22, 2022, which paid on March 2, 2022. The provider then submitted an exact duplicate claim on March 1, 2022, under a new claim number adding the 77-modifier. The second claim paid on June 30, 2022, and the original claim was recouped. With this appeal, the provider is now appealing the denial of the most recent claim submitted. The medical records only supported one chest scan being performed on February 18, 2022. The claims were billed by the same provider with no evidence of a second technical component being billed.
The Plan is correct in this case The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The claims in question were in the original case file. The records only support one scan being performed and that claim was paid. Therefore, we decided the Plan does not have to pay any additional claims submitted for code 71250-26-77 for date of service February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99291 billed to the enrollee for June 22, 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 for insufficient claim information in the case file. The Plan requested a reopen and provided additional claim information. The Plan demonstrated that the records show the provider billed code 12013 on date of service June 22, 2022. Payment for code 99291 is included in the global surgery payment for code 12013 provided on the same day. Therefore, the Medicare billing criteria are not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, code 99291 cannot be paid as payment for this service is included in the payment of code 12013. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99291) provided on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the equipment provided on November 23, 2022. 
 
You asked the Plan to pay for the equipment. The Plan denied your request. The Plan says that the claim did 
not include the clinical trial number. 
 
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. The Plan argues that the claim did not include the clinical trial number. 
However, the Plan has not provided documentation showing that the enrollee is enrolled in a clinical trial, or 
that the items in question were part of the clinical trial. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the equipment provided on 
November 23, 2022.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a stance flexion feature (L5845). 
 
You asked the Plan to pre-approve a stance flexion feature. You say that the policy requirements have been met 
for coverage. The Plan denied your request. The Plan says that the requested part is unbundled from the 
approved knee and cannot be requested separately. 
 
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. The Plan specifically did not substantiate their denial reason because their 
statement that the requested L5845 code cannot be billed with code L5814 due to unbundling is contradictory 
to Medicares rule that states L5845 must be billed in combination with an L-code for a knee-shin system. One 
of the examples Medicare rules give of a knee-shin system that L5845 can be billed in combination with is 
L5814. It is the burden of the Plan to substantiate their denial with evidence. In this case, the denial has not 
been substantiated. Therefore, we decided that the Plan has to pre-approve a stance flexion feature (L5845).  
 
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.