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 April 26, 2023, billed with 
procedure code 01992-QK. 
 
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 the claim is billed with an inappropriate modifier. 
 
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 01992 is anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional), prone position. 
 
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 with review of the anesthesia records 
it cannot be determined appropriate to use the modifier QK. In order to use this modifier, the physician 
performs medical direction of 2 to 4 concurrent procedures with anesthesia services and in some degree or 
another they overlap in time with the procedures. This time was not documented and 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 April 26, 2023, billed with procedure code 
01992-QK.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99222 billed for date of service May 20, 2022. 
 
You asked the Plan to pay for code 99222. You say that your coding department confirmed this code was billed 
correctly. The Plan denied your request. The Plan says that code 99222 is not supported by the medical record. 
The medical records don't support a comprehensive history. 
 
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 99222 is initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are 
provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the 
problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside 
and on the patients hospital floor or unit. 
 
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 code 99222. Our reviewer says that code 99222 is supported 
by the medical records. Our reviewer found the medical records support that there is a comprehensive history, a 
review of systems, a physical exam, and medical decision making of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have been met. Therefore, we decided that the Plan has to pay for 
code 99222 billed for date of service May 20, 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: 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 admission is a medical necessity. The Plan denied 
your request. The Plan says based on the available information, admission to IRF is not reasonable and 
necessary, as your condition does not meet the Medicare rules.  
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of spinal osteomyelitis. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do 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 you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99223 performed on March 24, 2023. 
 
You asked the Plan to pay for 99223. You say that 99223 should be paid as billed because it is supported in the 
medical record. 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 April 21, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for coverage of 99223 have not been met. Therefore, 
we decided that the Plan does not have to pay for the evaluation and management services described by code 
99223 performed on March 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a PET scan for the enrollee.

You asked the Plan to provide coverage for this imaging. The Plan denied your request. The Plan says the
Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen
stated that Maximus did not apply the correct criteria. The Plan noted the enrollee had newly diagnosed
melanoma. A PET scan was requested for initial staging. Per the NCD 220.6.17, PET scans are not covered for
the initial staging of regional lymph nodes and melanoma.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that PET scans not
covered for the enrollee's diagnosed condition. Therefore, we decided that the Plan does not have to provide
coverage for a PET scan for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the scan is needed due to abnormal findings on a 
previous computed tomography (CT) scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
pulmonary nodules. The record provided does not document a diagnosis of cancer. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown (D2740) and a core build-up 
(D2950) provided on May 22, 2023, to June 26, 2023. 
 
You asked the Plan to waive the coinsurance for D2740 and D2950. You say that you disagree with these 
charges. 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 50% 
coinsurance for out-of-network covered dental services.  
 
You have been asked to pay a 50% coinsurance for D2740 and D2950. This item/service falls within the dental 
services/comprehensive/out-of-network 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 coinsurance 
for a crown (D2740) and a core build-up (D2950) provided on May 22, 2023, to June 26, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services provided on March 13, 2023. 
 
You asked the Plan to pay for the infusion services. You say that the enrollee was not on hospice during this 
period. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for infusion services provided on March 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to an LTACH.  
 
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 that the enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules are not satisfied. 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 LTACH 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 the enrollee meets full IRF criteria and requires 
intensive inpatient rehabilitation with daily physician management, continuous specialized rehabilitation 
nursing, and intensive therapies to optimize mobility and strength while ensuring the restoration of functional 
status for a safe and sustainable discharge. The Plan denied your request. The Plan says the notes do not show 
that the enrollee's care specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; 
the notes do not show that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that the enrollee must have an intensive therapy program (3 hours a day, at least 5 days a 
week) in order to improve self-care functioning.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. 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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice services provided May 2, 2023, to May 30, 2023. 
 You asked the Plan to pay for the hospice services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that NOEs shall be filed within 5 calendar days after 
the hospice admission date. 
 
We looked at the file and Medicare rules. Review of the file shows that the NOE was not submitted within 5 
calendar days of starting hospice. Based on this information, we decided that Medicare rules for coverage of 
the hospice services have not been met. Therefore, we decided that the Plan does not have to pay for the 
hospice services provided May 2, 2023, to May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for upgraded electronics (E2311, E2377, and
E2313), push handles and assembly for the enrollee.

You asked the Plan to provide coverage for these accessories. The Plan denied your request. The Plan says
Medicare coverage criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria. The Plan noted the medical records show the
enrollee has adequate upper extremity strength to operate the standard switches that are included with the
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 does not provide coverage for upgraded push handles and/or
equipment assembly. The available clinical documentation in the case file does not support that the requested
upgraded electronics were medically reasonable and necessary for the enrollee. The upgraded push handles and
assembly are not covered by Medicare under any circumstance. Therefore, we decided that the Plan does not
have to provide coverage for upgraded electronics (E2311, E2377, and E2313), push handles and assembly for
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (AFO) provided by an out-of-network 
provider on June 8, 2023. 
 
You asked the Plan to pay for an AFO. You say that the AFO was medically necessary. The Plan denied your 
request. The Plan says the documentation requirements have not been met. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery (POD). The POD doesnt detail the specific item 
delivered to the enrollee to support the AFO (L1971). The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for an ankle foot orthosis (AFO) provided by an out-of-network provider on June 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
  You asked the Plan to pre-approve a home ventilator. You say that the patient requires non-invasive ventilation 
for life sustaining measures. You also say that failure to adequately ventilate will result in serious harm and/or 
death. The Plan denied your request. The Plan says this request for a home mechanical ventilator set in 
intelligent volume-assured pressure support (iVAPS) mode with auto-expiratory positive airway pressure that 
could be delivered by BiPAP is not covered. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has a diagnosis of 
COPD, and has had repeated hospitalizations. The patient is on multiple sedating medications. Arterial blood 
gases in the hospital were consistent with acute on chronic hypercarbic respiratory failure. Spirometry in 
December 2021 showed a forced expiratory volume in the first second (FEV1) of 68% of predicted, without 
evidence for airways obstruction. Our reviewer found that there is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. This patient may benefit from BiPAP with volume assurance during sleep as an 
outpatient. Our physician reviewer also found that he records do not show this has been tried and failed as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 19, 2023. 
 
You asked the Plan to pay for lab tests. You say that these tests were a crucial component in the diagnosis of 
the enrollee. The Plan denied your request. The Plan says these codes are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The CPT Code Manual definition of code 87640 
infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. The CPT Code Manual definition of code 87653 is infectious agent detection by nucleic acid (DNA or RNA); 
Streptococcus, group B, amplified probe technique. The CPT Code Manual definition of code 87798 is 
infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism. 
 
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 lab tests. Our reviewer says that these codes are not 
supported. Our reviewer found codes 87481, 87640, and 87653 would be included in code 87798 when 
reported correctly. As for code 87798, when reporting a "not otherwise specified" procedure, medical record 
should include procedures being reported with this procedure code. The procedure 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 lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on July 19, 2023.