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

 
We decided that the Plan has to pay for the thyroid testing (84443) provided on July 7, 2022. 
 
You asked the Plan to pay for the thyroid testing (84443). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that lab services ordered for screening 
purposes are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that thyroid testing billed with code 84443 is 
coverable when billed with diagnosis codes R25.2, R60.0, E11.9, and Z79.899. The claim in this case was 
billed with all these diagnosis codes. There is no evidence that this testing was ordered just for screening 
purposes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 84443 have been met. Therefore, we decided that the Plan has to pay for the thyroid testing 
(84443) provided on July 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on October 11, 2022, billed with 
codes 81291 and 81408. 
 
You asked the Plan to pay for the testing services. You say that the codes billed are correct. 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. The testing panel was not billed with a single panel code as required. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on October 11, 2022, 
billed with codes 81291 and 81408.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from January 13, 2021, to January 20, 2021, 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 diagnoses are supported by the physician's documentation. The Plan denied your request. The Plan says that the clinical evidence did not support the diagnoses.
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. Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital services at the DRG originally billed. In this case, you billed the inpatient services provided with principal diagnosis code A41.9 defined as Sepsis, unspecified organism. Our Medical Director states that the enrollee was admitted to the hospital on 1/13/2021 with urinary retention and sepsis, and an L5 compression fracture. Vital signs were notable for tachycardia, with a normal blood pressure and temperature. Laboratory studies were notable for no leukocytosis. Imaging demonstrated bilateral lower lobe mild airspace opacity, concerning for pneumonia. A urinary catheter was placed. Antibiotics were administered. Cultures were negative. Kyphoplasty was performed on 1/18/2021 and was well-tolerated. Our Medical Director found that the enrollee's condition did not meet Medicare criteria for the inpatient hospital services provided from January 13, 2021, to January 20, 2021, at the DRG originally billed. 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 to the enrollee from January 13, 2021, to January 20, 2021, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provider note indicates this enrollee has a favorable home setup and 
that her granddaughter will be caring for her after surgery. There is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay undergo this elective procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 1, 2022, billed 
with procedure codes 75630 and 99512. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says some of the billed services were approved on the appeal; however, 
procedure codes 75630 and 99512 remain unsupported. 
 
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 75630 and 99512 is Aortography, abdominal plus 
bilateral iliofemoral lower extremity, catheter, by sialography, radiological supervision and interpretation and 
Home visit for hemodialysis. 
 
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 medical services. Our reviewer says that the 
documentation does not support procedure codes 75630 and 99512. Regarding CPT code 99152, our coder 
found that the records submitted do not support that a home visit for hemodialysis was provided. The medical 
records include documentation of vascular services. Our reviewer found that regarding procedure code 99152, 
the records submitted do not support home visit for hemodialysis was provided and billed, and therefore cannot 
be verified. The medical records include documentation of vascular services provided. Regarding CPT code 
75630, our coder found that the operative report describes the performance of an intervention which includes 
radiological supervision and interpretation. Modifier -59 representing a distinct procedural service cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on November 1, 2022, billed with procedure codes 
75630 and 99512.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29075-59 and Q4010 provided on August 3, 
2022. 
 
You asked the Plan to pay for procedure codes 29075-59 and Q4010. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the 
services billed. 
 
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 29075 is a column II code to column I code 25605; however, 29075 
was billed with a modifier. 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 29075-59. 
Our reviewer says that the medical records do not support the use of modifier 59 with code 29075. Our 
reviewer found in this case, the same provider performed the closed fracture treatment, as well as the cast 
application during the same session.  Therefore, this procedure would be included in the primary procedure and 
not separately reported. 
 
In addition, the CPT Code Manual definition of code Q4010 is Cast supplies, short arm cast, adult (11 years +), 
fiberglass. We find that CPT code Q4010 is not supported in the medical record. Specifically, the record does 
not specify that the cast was made of fiberglass. 
 
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 codes 29075-59 and Q4010 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 29075-59 and Q4010 provided on August 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service December 7, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were submitted. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the records provided do not 
include a comprehensive history on the date of service at issue. 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 99223 billed for date of service December 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spineology OptiMesh cage. 
 
You asked the Plan to pre-approve Spineology OptiMesh cage. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 Spineology OptiMesh cage. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have low back pain with functional impairment and failure of 
conservative treatment. The Optimesh cage is not medically needed for this surgery. Structural allograft is appropriate. Pptimesh is experimental and more outcomes research is needed. Therefore, you do not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spineology OptiMesh cage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Spineology OptiMesh cage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010), custom fabricated abutments 
(D6057), implant-supported retainers (D6075), prosthetic maintenance/cleanings (D6011), sinus augmentation 
(D7951), and dental drugs/medicaments (D9630). 
 
You asked the Plan to pre-approve the dental services. You say that this is needed in order to be able to chew. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefits for the requested coverage of codes D6010, D6057, and D6075 have been exhausted by 
the approval of these codes that the Plan issued. Codes D6011, D7951, and D9630 are not covered by the Plan. 
Therefore, we decided that the Plan does not have to pre-approve implants (D6010), custom fabricated 
abutments (D6057), implant-supported retainers (D6075), prosthetic maintenance/cleanings (D6011), sinus 
augmentation (D7951), and dental drugs/medicaments (D9630).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 28, 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 partially overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information regarding payment of part of the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The MUE for code 87798 is 13. The MAI value for this code is 3. You billed 23 units of this code, exceeding the MUE by 10 units. You did not provide evidence to show the excess units were actually provided, correctly coded, and/or were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 87798 (10 additional units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 and 87640 billed for date of service 
November 7, 2022. 
 
You asked the Plan to pay for procedure code 87481 and 87640. The Plan denied your request. The Plan says 
payment for code 87481 and 87640 is bundled into payment for code 87801. 
 
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 87481 and 87640 is a column II code to column I code 87801. The 
codes at issue have 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 87481 and 87640 billed for date of service November 7, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 4, 2022.
You asked the Plan to pay for procedure code 76641. You say that these services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 10, 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 partially overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and indicated a portion of this claim had been paid.
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, we have confirmed that code 87634 is a column II code to column I code 87631. 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 the services described by procedure code(s) 87634.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300), attendant 
control (E2331), a cup holder (K0108), and a phone holder (K0108). 
 
You asked the Plan to pre-approve a power seat elevator, attendant control, cup holder, and phone holder. You 
say that the requested items are medically necessary. The Plan denied your request. The Plan says that a power 
seat elevator, cup holder, and phone holder are not primarily medical in nature. The Plan also says that an 
attendant control is not covered when provided in addition to a beneficiary-operated drive control system. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that if an attendant control is provided in addition to a beneficiary-
operated drive control system, it will be denied as non-covered. 
 
A power seat elevation feature, cup holder, and phone holder do not serve a purpose that is primarily medical in 
nature. The attendant control is not covered when provided in addition to a beneficiary-operated drive control 
system. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature 
(E2300), attendant control (E2331), a cup holder (K0108), and a phone holder (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20680 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 20680. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 20680 is bundled into payment for code 21627.  

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 20680 
is a column II code to column I code 21627 with a modifier indicator of 0. The column II 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 20680 billed for date of service July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by on March 22, 2022, to August 18, 2022. 
 
You asked the Plan to pay for the dental services provided. You say that this should be covered. The Plan denied your request. The Plan says the Provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided on March 22, 2022, to August 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650). 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the implantation is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the requested implantation. 
 
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 spinal cord stimulator trial. 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 chronic low back with radicular signs to his leg. He has 
started physical therapy. He is taking Percocet for pain. He had 2 epidural steroid injections. On March 6, 2023, 
he had an ESI which gave him 20 to 30% pain relief. On March 23, 2023, he had a second ESI which gave him 
50% for 1.5 weeks. There is no documentation of the results of a third injection. The request is for a SCS trial. 
There is no surgical consultation or history of past spine surgery. The enrollee does not have an evidence-based 
indication for a SCS trial.  The request is deemed not medically reasonable and 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural 
(63650).