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

 
We decided that the Plan does not have to pay for practitioner services provided on August 18, 2023, billed 
with evaluation and management (EM) code 99239. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that in this case, date of service billed is 
August 18, 2023, however medical record dates of service are conflicting and cannot be verified. Also, CPT 
99239 is a "timed" procedure code, which was not documented in the report. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 18, 2023, billed with evaluation and 
management (EM) code 99239.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene analysis of common variants (81226) provided on 
January 20,2023. 
 
You asked the Plan to pay for the gene analysis. You say that the service was billed correctly and should be 
paid. The Plan denied your request. The Plan says code 81226 was billed with modifier -GY which indicates 
that the service is not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services reported with modifier -GY are 
statutorily excluded from Medicare coverage and will be denied. 
 
The service in this case was billed with code 81226-GY. Based on this information, we decided that Medicare 
rules for coverage of the gene analysis have not been met. Therefore, we decided that the Plan does not have to 
pay for the gene analysis of common variants (81226) provided on January 20,2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that there are not enough studies on genicular nerve ablation for the 
treatment of knee osteoarthritis to show it is safe and effective, so it is not considered standard of care and not 
covered. 
 
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 genicular nerve ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this is considered an experimental/investigational procedure. It is the subject of 
ongoing clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the request prosthetic equipment.

You asked the Plan to provide coverage for these prosthetic items. The Plan denied your request. The Plan says
the records provided do not support the requested prosthetic items. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
enrollee's clinical history is not consistent with someone qualified for K3 ambulation. The enrollee is a
bilateral amputee. The enrollee has congestive heart failure (CHF) with EF of 41%. This is inconsistent with
K3 ambulatory function.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires specific medical
record documentation to show criteria for a K3 ambulation prothesis are met. Based on the records provided,
between the enrollee's comorbid conditions and amputation, the criteria required were not met. Therefore, we
decided that the Plan does not have to provide coverage for an all-lower extremity prosthesis, flex-walk system
(L5981), an all endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability
(L5984) and an addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the Dexcom G7 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says the coverage criteria 
are not 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 CGM. Our reviewer says that the 
requested CGM is not medically reasonable and necessary. Our physician reviewer found that although the 
enrollee takes glimepiride that can cause low blood glucose, the records do not show this. Additionally, there is 
no mention of a plan for insulin use. As such, the coverage criteria are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve  the Dexcom G7 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug testing (15-21 classes). 
 
You asked the Plan to pre-approve drug testing (15-21 classes). You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says this degree of testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that drug testing is only covered for certain indications. 
 
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 drug testing (15-21 classes). Our 
reviewer says that the documentation does not support that the requested drug testing is medically reasonable 
or necessary. Our physician reviewer found the enrollee has long term (current) use of opiate analgesic. The 
documentation does not support the need for the drug testing requested. This means the requested degree of 
testing is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug testing (15-21 classes) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve drug testing (15-21 classes).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 9, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on August 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87798, 87640, 87653, 87651, 87481 
and 87150) billed for date of service July 21, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not reported with a single panel 
code as required by Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87798, 87640, 87653, 87651, 87481 and 87150) billed for 
date of service July 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would greatly benefit from a 
LTACH level of care due to their complex medical care needs. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current setting. 
 
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 the enrollee is not safe for transfer at this time. There would be no therapeutic 
advantage in transferring the enrollee. 
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a VASS for a lower-limb prosthesis.

You asked the Plan to provide coverage for a vacuum-assisted suspension system (VASS) for a lower-limb
prosthesis. The Plan denied your request. The Plan says this equipment is not covered by Medicare. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria. The Plan noted that the use of vacuum pumps for residual limb volume management and moisture
evacuation systems among amputees is unproven and not medically necessary due to insufficient evidence of
safety and/or efficacy.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that investigational or
experimental equipment is not covered. Based on the equipment requested and the medical records, medical
necessity has not been established and this device is considered investigational. Therefore, we decided the Plan
does not have to provide coverage for a VASS for a lower-limb prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 7, 2022, to 
November 15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
service was billed correctly and should be paid. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate code 0T9DX0Z. 
 
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 procedure codes.   
 
In this case, you billed the inpatient services provided with ICD-10 procedure code 0T9DX0Z defined as 
drainage of urethra with drainage device, external approach. We asked our physician reviewer to carefully 
review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the 
request to pay for the inpatient hospital services at the DRG originally billed. Our physician reviewer found 
there was no documentation provided showing that the patient underwent drainage of the urethra with device 
procedure to justify this coding. Therefore, code 0T9DX0Z is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 7, 2022, to November 15, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV), power scooter 
(K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you are requesting an appeal for your power 
scooter. The Plan denied your request. The Plan says the medical necessity criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair or you cannot 
safely operate the PMD being requested. You refused to complete the assessment by the physical therapist. Without the assessment we cannot determine if a rollator and/or MWC (manual wheelchair) can meet your 
needs. To be approved for a POV you must complete a functional assessment and a successful trial of the 
device. You have not had a successful trial of the POV. We do not have evidence that you would be able to 
safely operate the POV. This means that Medicare rules for coverage of a PMD have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV), power scooter 
(K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical, multiple post collar, occipital/mandibular 
supports, adjustable (L0180) provided June 27, 2023. 
 You asked the Plan to pay for the cervical brace. You say that please see attached medical records The Plan 
denied your request. The Plan says the records do not support that this item was medically necessary, and the 
enrollee resides in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the cervical brace was used in a SNF or hospital. Therefore, we decided that the Plan does 
not have to pay for the cervical, multiple post collar, occipital/mandibular supports, adjustable (L0180) 
provided June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on May 26, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on May 26, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 provided on June 6, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
procedure code 99285. The Plan denied your request. The Plan says that the medical records do not support the 
billing of procedure code 99285. 
 
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 99285 is Emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. 
 
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 99285. Our reviewer says that the medical 
records support the billing of procedure code 99285. Our reviewer found the enrollee presented with head 
trauma on blood thinners. The enrollee was a high risk due to anticoagulation. A medically appropriate history 
and examination was performed. The records 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 99285 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99285 provided on June 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 01916 and 99140 billed for dates of service 
June 22, 2023, to June 23, 2023. 
 
You asked the Plan to pay for procedure codes 01916 and 99140. You say that this claim is not included in any 
other service. The Plan denied your request. The Plan says payment for code 01916 is bundled into payment for 
code 01924. The Plan also says that no payment can be made for code 99140. 
 
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 01916 
is a column II code to column I code 01924. 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. 
 
In relation to code 99140, we find that this code has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99140 is not separately payable. Therefore, we decided that the Plan does not have 
to pay for procedure code 01916 billed for dates of service June 22, 2023, to June 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from March 15, 2023, to  
April 5, 2023.  
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is not eligible to be paid for this service on this date. 
 
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 at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
March 15, 2023, to April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three genicular nerve blocks (64454). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is considered an experimental procedure. It is the subject of ongoing clinical trials.  
Therefore, 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve three genicular nerve blocks (64454).