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

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service March 14, 
2023. 
 
You asked the Plan to pay for procedure code 99255. You say that the diagnosis is appropriate for the date of 
service and payment should be allowed. 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 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
December 21, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. 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 the urine polymerase chain reaction 
(PCR) panel rendered on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel billed with codes 87150, 87801, 87798 
and 87481 for date of service February 9, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a 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 regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel billed with codes 87150, 87801, 87798 and 87481 for date of service February 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel billed with codes 87150, 87481, 87798 
and 87801 for date of service June 27, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a 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 regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel billed with codes 87150, 87481, 87798 and 87801 for date of service June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 billed for date of service April 5, 
2023. 
 You asked the Plan to pay for procedure code 97598. You say that the medical records support the billing of 
this code because of the extensive size of the wound treated. The Plan denied your request. The Plan says 
payment for code 97598 is bundled into payment for code 11043. 
 
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 97598 
is a column II code to column I code 11043. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 97598 billed for date of service April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 14, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on May 14, 2023, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on May 29, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support this level of care. 
 
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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that at least 75 
minutes were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99223) rendered on May 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan notes your ability to participate in intensive therapy was described as limited by the
hospital physical therapist. Given your inability to participate in physical therapy due to an elevated heart rate,
the Medicare coverage criteria were not met.

The Plan is correct in this case. 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.
Whether or not IRF case was thought to possibly be beneficial for you was not of issue. The coverage rules are
clear that enrollees must be able to physically participate in an intensive rehabilitation program provided by
this type of admission. Based on the medical records provided, there was not a clear expectation that you had
the ability to participate in this type of therapy program. Therefore, we decided that the Plan does not have to
provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 29, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on May 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0318 for date of service June 27, 2023. 
 
You asked the Plan to pay for procedure code G0318. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 G0318 is prolonged home or residence evaluation and 
management service(s) beyond the total time for the primary service (when the primary service has been 
selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified 
healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99345, 
99350 for home or residence evaluation and management services). (do not report g0318 on the same date of 
service as other prolonged services for evaluation and management 99358, 99359, 99417). (do not report g0318 
for any time unit less than 15 minutes).  
We find that CPT code G0318 is not supported in the medical record. Specifically, code G0318 must be billed 
with codes 99345 or 99350. The submitted claim does not support that the code at issue was billed with either 
99345 or 99350. Based on this information, we decided that Medicare rules for coverage of procedure code 
G0318 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0318 
for date of service June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 provided on June 21, 2023. 
 
You asked the Plan to pay for procedure code 99236. You say that the medical records support the billing of 
code 99236. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99236. 
 
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 99236 is Hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded. 
 
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 procedure code 99236. Our reviewer says that the medical 
records do not support the billing of code 99236. Our reviewer found the medical records do not support a high 
level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99236 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99236 provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99224 billed for date of service November 8, 2022. 
 
You asked the Plan to pay for code 99224. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code was billed with the wrong Place of Service 
(POS). 
 
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 99224 is subsequent observation care, per day. 
 
We find that CPT code 99224 is not supported in the medical record. Specifically, this code is for observation 
services.  Observation is an outpatient status.  However, you have billed Place of Service code 21, indicating 
that the services were performed in an inpatient hospital setting.  If the patient was receiving observation 
services, then POS 22 should have been used instead. Based on this information, we decided that Medicare 
rules for coverage of code 99224 have not been met. Therefore, we decided that the Plan does not have to pay 
for code 99224 billed for date of service November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Bioimpedance spectroscopy (BIS),
extracellular fluid analysis for lymphedema assessment. 

You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal this treatment
was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The NCCN Guidelines regarding Survivorship
Lymphedema does not recommend BIS in the management of lymphedema. The evidence in the medical
literature and the clinical documentation in this case are insufficient to support that bioimpedance spectroscopy
is medically reasonable and necessary in these cases. Therefore, we decided that the Plan does not have to
provide coverage for Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema
assessment.
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 enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support the need for an IRF admission. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epoetin alfa-epbx (Q5106). 
 
You asked the Plan to pre-approve epoetin alfa-epbx. You say that the patient could definitely benefit from 
erythropoietin therapy with 20,000 units every 2 weeks as needed and indicated by their low hemoglobin. The 
Plan denied your request. The Plan says this request does not meet medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that ESA treatment is not reasonable and necessary for 
beneficiaries with certain clinical conditions. 
 
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 epoetin alfa-epbx. Our reviewer says 
that the service is not reasonable or medically necessary.  Our physician reviewer found the patient has 
evidence of iron deficiency anemia, which is a limitation for coverage in the NCD, based on an acute drop in 
their hemoglobin from 10.8 to 9.6 in about 2 weeks and a low iron saturation. Our reviewer also found that the 
patient's iron should be repleted to determine if they still require erythropoietin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epoetin alfa-epbx have not been met. Therefore, we decided that the Plan does 
not have to pre-approve epoetin alfa-epbx (Q5106).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that your patient has already been treated with 
positive airway pressure (PAP) therapy, but this has shown to be insufficient. You also say that the patient 
needs advanced ventilatory support at home. The Plan denied your request. The Plan says based on Medicare 
guidelines, the home non-invasive ventilator (NIV) requested does not meet the requirements for approval.  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has COPD, 
obstructive sleep apnea, and severe kyphoscoliosis. The patient is non-compliant with CPAP. Pulmonary 
function tests on August 2, 2023, show a forced expiratory volume in the first second (FEV1) of 46% of 
predicted with a normal FEV1/forced vital capacity (FVC) ratio, and a normal total lung capacity and 
inspiratory and expiratory mouth pressures. Our reviewer found that there is no restrictive lung disease because 
the total lung capacity is normal. There is no diagnosis of neuromuscular disease. There is no arterial blood gas 
documenting chronic carbon dioxide retention. Our physician reviewer found if that is present, the patient may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a transforaminal epidural steroid injection (TFESI)
(64483).

You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal, this treatment
was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not
met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus did not apply
all of the required criteria

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules state for coverage of the
injection in question, enrollees should be participating in an active rehabilitation program, home exercise
program or functional restoration program. Based on the medical records provided, the enrollee was not
participating in any type of these programs at the time of the appeal. Medicare rules for coverage of this
treatment have not been met. Therefore, we decided that the Plan does not have to provide coverage for a
transforaminal epidural steroid injection (TFESI) (64483)..