Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room (ER) visit provided on January 10, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says that the services denied correctly as they were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an emergency 
room (ER) visit provided on January 10, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a 
prophylaxis (D1110). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee is very fragile in her health. 
Going to a dental office is difficult. The requested provider visits the enrollee's home to do basic dental work. 
The Plan denied your request. The Plan says dental services from an out-of-network provider are not covered 
by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) and a prophylaxis (D1110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
February 8, 2023, to March 6, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the device rendered is not a covered benefit. 
 
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 the pneumatic compression device (E0675) provided on February 8, 2023, to March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 
and full arm and trunk appliances. 
 
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. Medicare rules say that an E0652 PCD is covered when specific criteria 
are met. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the enrollee has lymphedema of the upper 
extremities and extending into her trunk. There is no documentation of a four-week trial of conservative 
therapy demonstrating failed response to treatment with an E0650 or E0651 basic pump. The criteria for 
coverage are not met and the E0652 PCD and accessories 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) coded E0652 and full arm and trunk appliances.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital care admission. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that the inpatient admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the elective procedure to 
implant a baroflex device was approved. The procedure is not on the Centers for Medicare & Medicaid 
Services, (CMS) inpatient only list. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 inpatient hospital admission. Our 
reviewer says that the documentation does not support criteria for an inpatient hospital admission. Our 
physician reviewer found the review indicates that the enrollee is medically stable and has given medical 
clearance for the elective procedure. The planned procedure is not listed on the CMS Inpatient Only List. The 
procedure is currently approved as an ambulatory procedure. The review has determined that the record did not 
show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an acute inpatient hospital care admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that after your injury you were bedridden too long and 
you need more rehabilitation. The Plan denied your request. The Plan says you do not require continued daily 
skilled nursing or skilled therapy services.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary computed tomography (CT) with calcium 
scoring. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records indicate the enrollee has 
signs or symptoms attributable to possible cardiac disease. The record indicates that the requested test is being 
performed for screening purposes and does not indicate how the requested test would later the management of 
the enrollee's clinical presentation. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness of the requested service. The coronary CT with calcium scoring is not reasonable or medically 
necessary at this time. 
 
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 coronary computed tomography (CT) with calcium scoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the finger orthoses you purchased on April 26, 2023. 
 
You asked the Plan to pay for the finger orthoses. You say that you believe these items are covered by your 
plan. The Plan denied your request. The Plan says you purchased these items from an ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider from whom you purchases these orthoses is 
not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the finger 
orthoses you purchased on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on May 1, 2023. 
 You asked the Plan to pay for the urine PCR panel testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the unbundling of lab codes for PCR panel testing is not 
appropriate. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that urinary tract infection panel, including antibiotic resistance markers utilizing 
PCR testing of the urine, was performed. The standard of care for the evaluation or urinary incontinence is 
urinalysis with urine culture and sensitivity. The PCR panel testing is considered excessive testing and not 
medically necessary. This means the urine PCR panel testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the urine polymerase chain reaction (PCR) panel testing provided on May 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) joint 
fusion. 
 
You asked the Plan to pre-approve SI joint fusion. You say that records support the medical necessity of this 
procedure. The Plan denied your request. The Plan says imaging does not show SI joint instability, fracture, or 
lesion. 
 
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 SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented SI joint instability, fracture, or lesion. SI joint fusion for degenerative 
back pain is experimental.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve minimally invasive percutaneous sacroiliac (SI) joint fusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires 25-30 days in a 
LTACH to regain their prior level of functioning. The Plan denied your request. The Plan says the request is 
not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 77063 provided to the enrollee on July 14, 2022.
You asked the Plan to pay for procedure code 77063. You say that the primary code was submitted and paid.
The Plan denied your request. The Plan says that this claim has an add-on code without a primary, so it cannot
be paid. Maximus overturned the denial for code 77063. The Plan requested a reopen and provided additional
information regarding the appropriate billing of this code. The Plan noted that on the physician fee schedule the
"ZZZ' indication means that this code is related to another service and is always included in the global period
of the other service billed. The Reimbursement Policy (CMS 1500), Add-On Codes Policy for Addon to
Primary Code Relationship List; includes add-on codes which will only be reimbursed when reported with the
appropriate primary code. The Plan submitted this code list. The Plan notes that as the code 77063 was billed
without an appropriate primary code and not performed by the same practitioner on the same date of service,
the Medicare rule for payment of code 77063 has not been met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code.
In this case, code 77063 has the "ZZZ" indicator requiring that this code be billed with an appropriate primary
code which was not reflected on the submitted claim. Medicare rules of this code have not been met. Therefore,
we decided that the Plan does not have to pay for procedure code 77063 provided to the enrollee on July 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion at L5-S1. 
 
You asked the Plan to pre-approve a lumbar fusion. You say that this procedure would improve the enrollee's 
condition. The Plan denied your request. The Plan says the medical criteria for a lumbar fusion have not been 
met. 
 
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 lumbar fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the imaging shows L5-S1 without instability, fracture, or lesion. 
 
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 lumbar fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar fusion at L5-S1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service June 5, 2023. 
 
You asked the Plan to pay for procedure code S9083. You say that this claim has already been processed by the 
enrollee's primary insurance. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
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 S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) billed for date of service April 3, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says there is insufficient information in the physician order 
provided to verify that these services were necessary and explicitly requested by the enrollee's physician. 
 
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 does not specify which drugs are requested for testing in this case. Without 
this information, we cannot verify that the services provided were actually 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 (G0483) billed for date of service April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 24, 2023, billed with 
procedure code 99213. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to bill a left and 
right sided diagnosis code when a bilateral code is available.  
We looked at 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. This claim has not been billed with the 
appropriate bilateral diagnosis code. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on April 24, 2023, billed with procedure code 99213.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code H0004-GY billed for date of service April 3, 2023. 
 
You asked the Plan to pay for code H0004-GY. You say that the billed charges are supported. The Plan denied 
your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that services billed with the GY modifier will be 
automatically denied because the GY modifier indicates that it is an excluded service. 
 
In this case, you billed the code in dispute (H0004) with the GY modifier.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code H0004-GY have not been met. Therefore, we decided that the Plan does not have to pay for 
code H0004-GY billed for date of service April 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only modic changes without facet degenerative joint disease or foraminal stenosis. The cause 
of the enrollee's pain is not clear. The Intracept procedure is therefore not reasonable or medically necessary at 
this time. 
 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 an Intracept procedure.