Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71100 billed for date of service October 20, 
2022.  
 
You asked the Plan to pay for procedure code 71100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71100 is bundled into payment for code 
71101. 
 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 71100 
is a column II code to column I code 71101 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 71100 billed for date of service October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88104 billed for date of service January 17, 
2023.  
You asked the Plan to pay for procedure code 88104. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 88104 is bundled into payment for code 88112. 
 
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 88104 
is a column II code to column I code 88112. 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 88104 billed for date of service January 17, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on June 21, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test is covered and should be paid. 
The Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on June 21, 2022.
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 you have low strength due to current medical 
condition and require an IRF admission. The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9975 billed for date of service March 23, 
2022, to April 29, 2022. 
 
You asked the Plan to pay for procedure code S9975. You say that the charges were medically necessary. 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 S9975 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9975 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9975 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9975 billed for date of service March 23, 2022, to April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service December 
13, 2022. 
 
You asked the Plan to pay for procedure code A4550. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4550 is considered bundled and not separately 
payable.  
 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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service December 13, 2022.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a weight loss procedure that is to be done in Mexico. 
 
You asked the Plan to pre-approve a weight loss procedure that is to be done in Mexico. You say that the 
services are necessary. The Plan denied your request. The Plan says the requested service is planned and not an 
emergency or urgent. Therefore, the service to be performed in Mexico is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for certain services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a weight loss procedure that is to be done in Mexico have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a weight loss procedure that is to be done in Mexico.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transurethral waterjet ablation procedure (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation. You say that the requested services are a 
medical necessity for the enrollee. 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 transurethral waterjet ablation. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case.  
Our physician reviewer found that the records do not show that the enrollee has a maximum urinary flow rate 
(Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 cc). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transurethral waterjet ablation procedure (0421T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99358) provided on January 31, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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, the CPT Code Manual definition of code 99358 is Prolonged evaluation and management service 
before and/or after direct patient care, first hour. 
 
We find that CPT code 99358 is not supported in the medical record. Specifically, the records provided do not 
support the CPT code used. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99358) provided on January 31, 2023.
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 was advised he was pre-approved but 
then received a letter stating an IRF admission was denied. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit (99285) infectious agent antigen 
detection by immunoassay with direct optical observation (87811) provided July 30, 2022. 
 
You asked the Plan to pay for the emergency visit. You say that you would like to reconsider your claim for 
additional payment as the services rendered were emergency services that were medically necessary. The Plan 
denied your request. The Plan says the services were rendered by a provider who is not eligible to participate in 
Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the 
full cost of the services you receive.  
 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 emergency department visit (99285) 
infectious agent antigen detection by immunoassay with direct optical observation (87811) provided July 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 11, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were rendered in good faith. 
The Plan denied your request. The Plan says 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
service 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 physician's services provided on January 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for November 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 8, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met.  Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 for 
November 27, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that that the admission to a SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing needs. You do have documented 
skilled therapy needs. Daily skilled services are required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
 
 
 
 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on December 10, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 10, 2022. A NOA was not received by the Plan within 5 days of 
the start of care date. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health services provided on December 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says that inpatient care is not necessary. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for acute inpatient hospital care. Our Medical Director states that the documentation does not support that it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment billed with code G2067 for 
January 23, 2023. 
 
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 provider is not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
billed with code G2067 for January 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99284 & 99053 billed for date of service 
November 29, 2022. 
 
You asked the Plan to pay for procedure codes 99284 & 99053. You say that these services were medically 
necessary. The Plan denied your request. The Plan says payment for these codes is bundled into other services. 
 
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 99284 
is a column II code to column I code 99285. Code 99053 has a status indicator of "B". 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 codes 99284 & 
99053 billed for date of service November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
28, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 28, 2022.