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

We decided that the Plan does not have to pay for the evaluation and management services described by code 99204 performed on June 30, 2023.

You asked the Plan to pay for 99204. You say that 99204 should be paid as billed because it is supported in the documentation. The Plan denied your request. The Plan says 99204 is not supported in the documentation.

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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.

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 99204. Our reviewer says that 99204 is not supported in the documentation. Our reviewer found the enrollee is an 87-year-old who was reported as having been seen as a new patient at a cardiology office for follow-up. The documentation described the enrollee as reporting occasional leg heaviness and leg pain on ambulation. Vitals were stable. Medications were continued as before without any planned treatment changes. The provided documentation included an appropriate history and examination but did not support medical decision making of moderate complexity, as required. Also, the time duration of the encounter was not clearly documented as lasting 45-59 minutes.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 99204 have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services described by code 99204 performed on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950), and retainer crown - porcelain/ceramic (D6740) for tooth #21. 
 
You asked the Plan to pre-approve the core buildup and retainer crown - porcelain/ceramic for tooth #21. You 
say that the enrollee does not require a splint, it would be a fixed bridge. You also ask to please review the 
submitted panoramic for review. The Plan denied your request. The Plan says coverage excludes any service 
related to splinting teeth including multiple abutments. The criteria for core buildup #21 have not been met 
because the bridge retainer crown #21 has been denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the the core 
buildup and retainer crown - porcelain/ceramic when the services are medically necessary and reasonable.  
 
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 core buildup and retainer crown - 
porcelain/ceramic for tooth #21. Our reviewer says that the dental service is not medically necessary. Our 
physician reviewer found both the panoramic x-ray and the full mouth series of x-rays only show part of the 
teeth in the mouth as the x-rays seem to be cut off either due to photocopy or how the images were printed. 
Teeth #'s 23, 24, and 25 are missing. Tooth #26 is broken with most of the tooth structure missing. Tooth #21 
has a large amalgam filling and there is not a periapical x-ray or bitewing of tooth #21 as these images do not 
show up in the documentation. I am able to see tooth #21 in the panoramic x-ray, but this is not an adequate 
image to make a diagnosis of the tooth. Without a more detailed x-ray images such as a periapical or bitewing 
x-ray, or a photograph, one cannot make the determination. Due to the missing images of the left side of the 
mouth in the full mouth series, I cannot diagnose whether a core build up is required for this tooth. More 
information is needed for tooth #21 of whether a core build up or a crown is necessary. Based on the 
information provided these services are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the core buildup and retainer crown - porcelain/ceramic have not been met. 
Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins when 
required (D2950), and retainer crown - porcelain/ceramic (D6740) for tooth #21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), a harness (E2313) 
and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the upgraded electronics 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 wheelchair accessories. 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 a spinal cord injury following spinal surgery. She is able to feed 
herself and groom and dress upper body. Per Social Security Administration (SSA) 1862 (a)1(A), the requested 
accessories are not medically necessary as the enrollee has adequate strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), a harness (E2313) and an expandable controller 
(E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bracket assembly accessory (K0108 x 2), expandable 
controller (E2377), harness for upgrade to expandable controller (E2313), and an electronic connection 
between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve a bracket assembly accessory, expandable controller, harness, and an 
electronic connection. You say that the services are necessary. The Plan denied your request. The Plan says 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 bracket assembly accessory, 
expandable controller, harness, and an electronic connection. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical record documentation from the physician does not support that the enrollee requires all of 
the upgraded electronics requested. Provided records document that the enrollee has 4+/5 right upper extremity 
strength with function and range of motion rated as within functional limits and she is setup assist with 
grooming, feeding and meal preparation thus indicating she has adequate right upper extremity strength and 
function to operate the wheelchair's power options with their own switches. No documentation of a unique 
physical deformity or condition is provided in the records to support the necessity of the bracket assembly 
accessory (K0108 x 2) for attaching a seat belt. 
 
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 bracket assembly accessory, expandable controller, harness, and an electronic 
connection have not been met. Therefore, we decided that the Plan does not have to pre-approve a bracket 
assembly accessory (K0108 x 2), expandable controller (E2377), harness for upgrade to expandable controller 
(E2313), and an electronic connection between wheelchair controller and two or more power seating system 
motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested upgraded electronics.

You asked the Plan to provide coverage for these accessories. The Plan denied your request. The Plan says the
Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria. The Plan noted that an E2377 Expandable
Controller, E2313 Expandable Controller Harness and E2311 electronic accessory are requested to control
power tilt, recline, and power elevating leg rests through the joystick. The medical records do not reflect a
medical need to control these power options through the joystick. The medical records show the enrollee has
full strength in the left area and the enrollee's upper limb strength and function are adequate for the enrollee to
be able to control the power options using their own switches which are included in the basic power
wheelchair.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare has specific coverage criteria for upgraded electronics. The available
clinical documentation does not support that the requested upgraded electronics were medically reasonable and
necessary for the enrollee in this case. The notes do not show the medical necessity of controlling the power
options through a joystick. Therefore, we decided that the Plan does not have to provide coverage for an E2377
Expandable Controller, E2313 Expandable Controller Harness and E2311 electronic accessory are requested to
control power tilt, recline, and power elevating leg rests through the joystick for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 You asked the Plan to pre-approve a pneumatic compression device and a garment. You say that a PCD coded 
as E0651, has no garments or capability to treat lymphedema that extends beyond the extremities, thus 
adequate compression cannot be achieved in those areas. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for approval of the requested device. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and a 
garment. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has chronic venous insufficiency and lower extremity lymphedema. There is no documentation of the 
enrollee's non-responsiveness to a trial of conservative therapy. There is no documentation of edema extending 
above the lower extremities. As such, the enrollee does not meet clinical guidelines for use of PCD based on 
submitted documentation. In summary, authorization, and coverage of the PCD would not be considered 
medically necessary in this enrollee's clinical management. 
 
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 pneumatic compression device and a garment have not been met.  Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232-57 billed for date of service January 1, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the code is separately billable. The Plan denied your 
request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232-57 is not supported. We find that code 99232-57 was billed with minor 
procedure code 27197. Modifier -25 is used to facilitate billing of evaluation and management services on the 
day of a minor procedure for which separate payment may be made. Based on this information, we decided that 
Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99232-57 billed for date of service January 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment the podiatry service provided on July 24, 2023. 
 
You have asked the Plan to waive the copayment for the podiatry service. You say that this was not a regular 
office visit and that you would like the $40 copayment to be waived. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered podiatry services. 
You have been asked to pay a $40 copayment for the podiatry service. This service falls within the podiatry 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry service 
provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 5, 2023, billed with 
procedure code 99214-25. 
 
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 follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We asked our coding 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 practitioner services provided. Our 
reviewer says that documentation does not support the billed code. Our physician reviewer found that the 
procedure report describes wound care assessment and wound care was provided. In this case a significant, 
separately identifiable evaluation and management service was not included in the documentation submitted 
and therefore the procedure code and modifier reported separately 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 5, 2023, billed with procedure code 
99214-25.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely provided in other settings.  
 
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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for non surgical management of a pelvic fracture after a fall.  Medical problems are stable. There are 
no complex nursing or rehabilitation needs. The patient 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 and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
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: 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 this is medically necessary. The Plan denied your 
request. The Plan says the services could be provided in other settings.  
 
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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for sepsis, myocardial infarction, and atrial fibrillation. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient 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 and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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 an epidural steroid injection (62322). 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injections are covered when specific 
criteria are met. 
 
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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the required duration 
of pain relief has not been achieved and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62322).