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

 
We decided that the Plan does not have to pay for procedure codes 93923, 95921, 95922, and 95923 billed for 
October 27, 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 codes 93923, 95921, 95922, and 95923 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 93923 is Complete bilateral noninvasive physiologic 
studies of 3 or more levels of lower extremity arteries. The definition of code 95921 is testing of autonomic 
nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the 
following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio. 
The definition of code 95922 is testing of autonomic nervous system function; vasomotor adrenergic 
innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes 
during Valsalva maneuver and at least 5 minutes of passive tilt. The definition of code 95923 is testing of 
autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor 
axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin 
potential. 
 
We find that CPT codes 93923, 95921, 95922, and 95923 are not supported in the medical record. Specifically, 
there is no detailed procedure note that documents testing of autonomic nervous system function, cardiovagal 
innervation, including two or more of the following: heart rate response to deep breathing with recorded R-R 
interval, Valsalva ratio, and 30:15 ratio to support code 95921. There is no documentation of testing of 
autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor 
axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin 
potential was performed to support code 95923. There is no documentation of a detailed procedure report that a 
complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels, or 
single level study with provocative functional maneuvers to support code 93923. There is no documentation of 
testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic 
function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at 
least 5 minutes of passive tilt to support code 95922. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 93923, 95921, 95922, and 95923 
billed for October 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service February 1, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records show medical necessity. The 
Plan denied your request. The Plan says the billed code 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. We looked at the file and the rules. 

We find that 1 unit of CPT code 20610 was billed and paid for by the Plan. 
An addition unit for CPT code 20610 is not supported in the medical record. 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 20610 billed for date of service February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E2601 billed for date of service November 
10, 2022.  
 
You asked the Plan to pay for procedure code E2601. 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 E2601 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 E2601 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code E2601 billed for date of service November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodontal maintenance (D4910) 
provided on November 21, 2022. 
  
You asked the Plan to issue reimbursement for this dental service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the service provided 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 benefit for the service provided was exhausted on date of service July 20, 2022. Specifically, the 
Plan's contract states that periodontal maintenance is covered twice per calendar year. You previously received 
this service on April 20, 2022 and July 20, 2022 accordingly, which was paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to issue 
reimbursement for the periodontal maintenance (D4910) provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional office visits to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve 5 additional office visits. You say that you have been experiencing 
lightheadedness when doing chores and using stairs. You say that you cannot see a network cardiologist until September. You also say that you would like once more appointment with this provider. The Plan denied your 
request. The Plan says there is no unique reason or rationale why further out-of-network cardiologists need to 
be seen. The Plan also says there are multiple network cardiologists available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
5 additional office visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 28, 2022, billed 
with codes 81227, 81231, 81232, 81306, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. 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. 
 
The file shows that a comprehensive gene panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single panel code as required. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing provided on November 28, 2022, billed with codes 81227, 81231, 
81232, 81306, and 81335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640 and 87491 billed for date of service 
February 8, 2023. 
 
You asked the Plan to pay for procedure codes 87640 and 87491. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 87640 is 
bundled into payment for code 87641. Additionally, the records do not support that infectious agent detection 
by nucleic acid for Chlamydia trachomatis was performed. 
 
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 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, the records do not support that infectious agent detection by nucleic acid for 
Chlamydia trachomatis was performed. 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 codes 87640 and 87491 billed for 
date of service February 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor. Our reviewer says that a continuous glucose monitor is not medically necessary. Our physician reviewer found the records provided do not indicate that the enrollee is being treated with insulin or has problematic hypoglycemia as defined by Medicare rules.

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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hemodialysis procedure with single evaluation by a 
physician or other qualified health care professional (90935) and unlisted dialysis procedure (90999) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve hemodialysis and unlisted dialysis procedures. You say that you disagree 
with the denial. You also say that you are requesting a temporary authorization until the enrollee is placed at 
another facility by the Plan or the enrollee decides to disenroll with the Plan. The Plan denied your request. The 
Plan says the enrollee must receive services from a network provider. There are in-network providers within a 
reasonable distance from the enrollee's location that can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Please note that the Plan has approved 3 months of visits with the 
OON provider to allow the enrollee time to work with the provider to transition the enrollee's care to an in-
network facility. Therefore, we decided that the Plan does not have to pre-approve a hemodialysis procedure 
with single evaluation by a physician or other qualified health care professional (90935) and unlisted dialysis 
procedure (90999) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months of continued use of a noninvasive 
ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve continued use of a NIV. You say that the enrollee has been compliant 
throughout therapy and benefitting from a NIV. Hospital admissions have declined drastically as well as an 
improvement in the enrollee's quality of life overall. The Plan denied your request. The Plan says the request 
for continued use of a NIV is not medically reasonable and necessary. 
 
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 continued use of a NIV. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from obstructive sleep apnea and obesity hypoventilation syndrome. 
The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. The enrollee could be treated with a bilevel positive airway pressure 
(BiPAP) machine with average volume-assured pressure support (AVAPS) capability and failure of such a 
device has not been documented. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a NIV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine (9) months of continued use of a noninvasive ventilator (NIV) (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation code 99153 provided on date of service 
December 8, 2022. 

You asked the Plan to pay for procedure code 99153. You say that medical records were provided. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
The claim shows that the services at issue were provided in an ambulatory surgical center. We find that 
payment for CPT code 99153 is not payable in this case. There is no separate payment to the physician for CPT 
code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for 
moderate sedation code 99153 provided on date of service December 8, 2022.
Appeal type: Home Health
Decision: Partially Favorable

We decided that the Plan has to pre-approve two (2) home health physical therapy visits (G0151 x2). We decided that the Plan does not have to pre-approve home health skilled nursing visits (G0299 x5). 

You asked the Plan to pre-approve the home health skilled nursing visits (G0299 x5) and home health physical therapy visits (G0151). . You say that the services are medically necessary. The Plan says that the services are not medically necessary.

We decided that the Plan has to pre-approve two (2) home health physical therapy visits (G0151 x2). 

The Plan follows Medicare rules. 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 home health physical therapy visits. Our reviewer says that the enrollee has significant fall risk and limited endurance. Not quite walking at a community level. Our physician reviewer states it is necessary to authorize two (2) physical therapy (PT) visits to address fall risk and review fall prevention exercises.

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 home health physical therapy visits have been met. Therefore, we decided that the Plan has to pre-approve two (2) home health physical therapy visits (G0151 x2). 

We also decided that the Plan does not have to pre-approve home health skilled nursing visits (G0299 x5).

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 skilled nursing visits (G0299 x5). Our reviewer says that the skilled nursing visits are not necessary. The skilled nursing is focused on fall risk and it is redundant with PT visits.

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 skilled nursing visits (G0299 x5) have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits (G0299 x5).

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: Favorable

We decided that the Plan has to pay for the deep sedation (D9222 and D9223) provided on October 22, 2022.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that deep sedation is
not covered by the dental benefit. Maximus upheld the Plans denial. It was then discovered on quality review
that the Plan did not send the correct contract information for 2022.
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 submitted the 2023 contract for review instead of the 2022 contract, which was the year the
services took place. Therefore, we decided that the Plan has to pay for the deep sedation (D9222 and D9223)
provided on October 22, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 10 additional occupational therapy visits for the
enrollee.
You asked the Plan to provide coverage for additional occupational therapy. You say that additional
occupational therapy is medically necessary. The Plan denied your request. The Plan says Medicare coverage
criteria are not met.
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. Our Medical Director looked at the case file. At issue is coverage for 10 additional occupational therapy
visits. The Maximus Physician Reviewer determined that skilled services are not necessary to restore or
maintain function or to prevent deterioration of the enrollee's condition. The reviewer found that the enrollee
has previously been treated with outpatient therapies and should be independent with a home exercise program.
The enrollee has no recent injury or a decline in function. The additional therapy services are not appropriate
duration and frequency for treatment of the enrollee's medical condition and therefore are not medically
necessary. The case has been reopened to make sure occupational therapy was reviewed.
The enrollee is a 75-year-old man with a medical history that includes Parkinson's Disease with falls. The
enrollee has been receiving occupational therapy for the treatment of his medical condition primarily to
improve the use of his right upper extremity. The documentation does not support that 10 additional
occupational therapy visits are medically reasonable and necessary for the enrollee in this case. The Medicare
guidelines state that if at any point in the treatment it is determined that the treatment becomes repetitive and
does not require the unique skills of a therapist, the services are non-covered. In this case, there is insufficient
documentation of improvement in response to therapy, with continued falls and minimal improvement with
therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional occupational therapy have not been met. Therefore, we decided that
the Plan does not have to provide coverage for 10 additional occupational therapy visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image and topical application of 
fluoride (D0330, D1206) provided on January 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic radiographic image and topical application of fluoride (D0330, D1206) provided on January 12, 
2023.