Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a heavy-duty deluxe foam mattress.
You asked the Plan to provide coverage for this mattress. You say that at the time of the appeal, the requested mattress was medically necessary. The Plan denied your request. The Plan says there is insufficient medical records to show this mattress is medically necessary. Maximus overturned the Plans denial for insufficient information in the case file .The Plan requested a reopen and provided the required information.
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. There were no medical records provided from your physician, after several requests by the Plan, to show the requested mattress was medically necessary.
Medicare rules for coverage of this mattress have not been met. Therefore, we decided that the Plan does not have to provide coverage for a heavy-duty deluxe foam mattress.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for code 66984 provided on October 31, 2022
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case fille. The Plan requested are reopen and provided additional information. The Plan noted that the claim history shows procedure code 66984 was already billed and paid on November 07, 2022, under check number. The procedure code 66984-LT billed by the same provider exceeds the allowable units of 1 for the MUE of 2. The Plan submitted additional claim information for review
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim exceeds the Medicare allowed MUE for the code billed due to a previous payment. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 66984 provided on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for glucose test strips, 4 daily or 120 strips per 30 days.
You asked the Plan to provide coverage for glucose test strips, 4 daily or 120 strips per 30 days. You say that the quantity requested is medically necessary The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen 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 glucose test strips, 4 daily or 120 strips per 30 days. The medical records show the enrollee is a 68-year-old woman with type 2 diabetes, not being treated with insulin, based on information on the Prior Authorization Request Form. It is noted on the Prior Authorization Request Form that the enrollee has labile blood sugars and needs to test 4 times per day. There is no clinical documentation supporting that the coverage criteria for glucose test strips, 120 strips per 30 days, have been met in this case. There is no documentation that within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described above. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of glucose test strips, 4 daily, 120 strips per 30 days have not been met. Therefore, we decided that the Plan does not have to provide coverage for glucose test strips, 4 daily or 120 strips per 30 days.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine testing billed to the enrollee for December 29, 2022, and billed under codes 87801, 87150, 87481, and 87798.
You asked the Plan to pay for this claim as billed . You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file regarding the denial. The Plan requested a reopen and noted that a test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components although the test reports multiple individual pathogens and/or targets. Medicare coding rules indicate stacking of codes in unacceptable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim could not be paid as billed as only one code can be reported and paid for this type of testing. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for urine testing billed to the enrollee for December 29, 2022, and billed under codes 87801, 87150, 87481, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for stereotactic radiosurgery (SRS) for the enrollee.
You asked the Plan to provide coverage for stereotactic radiosurgery (SRS). You say that this treatment is medically necessary. The Plan denied your request. The Plan says the prior authorization was not submitted correctly. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated this was a submission issue for coding. The Plan noted that the provider is planning radiosurgery. The provider requested authorization for 5 units of 77371. Code 77371 describes radiosurgery with a Cobalt-60 radiation source. The provider explicitly documented a Cobalt-60 source would not be used. Code 77372 describes single session linac based radiosurgery, and the provider stated a linac would be used. Code 77371 describes radiosurgery in one all-inclusive treatment course. The Plan notes the use of the 77371 code for 5 units in a radiosurgery course that is fractionated would represent overbilling and/or improper coding.
The code 77373 is used for multi-fraction SRS. This can be seen in the https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3471CP.pdf. Medicare rules dictate that when a code is submitted, the procedure described by the code must be performed. The provider documented that they would not actually be performing Cobalt-60 radiosurgery and would be performing linac radiosurgery described by another CPT code. Medicare rules also strictly forbid using 77371 for multi-fraction radiosurgery. None of the provider's documentation (linac radiosurgery, multi-fraction radiosurgery) is described by the submitted 77371 code(s).
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. Based on the records provided, the request for approval of this service was not submitted with the appropriate codes. Therefore, we decided that the Plan does not have to provide coverage for stereotactic radiosurgery (SRS) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care received from April 17, 
2021, through June 30, 2021.  
 
You asked the Plan to pay for the SNF care. You say that you were unaware that you would have to pay for the 
services. The Plan denied your request. The Plan says the claim was untimely, and the submission did not meet 
the exception criteria. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the SNF care was not filed until February 17, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for skilled nursing facility (SNF) care received from April 17, 2021, through June 
30, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from July 11, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services from July 11, 2023, forward. You say 
that the services are medically necessary. The Plan denied your request. The Plan says that the requested 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services 
from July 11, 2023, forward. Our reviewer says that this enrollee does meet the criteria for July 11, 2023, 
forward as this enrollee was shown to be uncooperative, quite delusional and showing threats of safety. Our 
physician reviewer found the enrollee did appear to require inpatient mental health treatment beyond the date in 
question as she was difficult to redirect and quite paranoid. It did appear that active treatment was taking place 
beyond the date in question. It did appear that the services were reasonably expected to improve the enrollee's 
condition or for the purpose of diagnosis beyond the date in question. This enrollee was treated under an 
individualized treatment plan found in the record. It did appear that the records were supervised and evaluated 
by a physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services from July 11, 2023, forward have been 
met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from July 11, 2023, 
forward.   

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service February 14, 
2023. 
 
You asked the Plan to pay for the billed services. You say that authorization was provided. The Plan denied 
your request. The Plan says separate payment is limited for this procedure. 
 
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 procedure code 69990 is an add-on code and has not been billed with an 
appropriate primary procedure code. 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 69990 billed for date of service 
February 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99292, 93005, and 93041 for date of service 
January 28, 2023. 
 
You asked the Plan to pay for procedure codes 99292, 93005, and 93041. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Review of the file shows that code 99292 has a status indicator of 
"N". This means code 99292 is never separately payable. Codes 93005 and 93041 have a status indicator of Q1. 
Code 99291 was billed on the same date of service with a revenue code of 450. Codes 99292, 93005, and 
93041 are not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure codes 99292, 93005, and 93041 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99292, 93005, and 93041 for date of service January 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 3, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity.  
 
We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee was 
seen in the emergency room for pain after a fall. She was found to have wrist and leg fractures. The enrollee 
was in stable condition and in no acute distress. The records do not show medical decision making of high 
complexity. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 billed for 
date of service November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 
23, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the enrollee was seen twice on the same date 
of service by different providers. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, and 87641 billed for 
date of service November 7, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, and 87641. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, 87653, 
and 87641 is bundled into payment for other codes. 
 
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 87150 
is a column II code to column I code 87500. We have confirmed that codes 87481, 87653, and 87641 are 
column II codes to column I codes 87150 and 87801. 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 87150, 87481, 87653, and 87641 
billed for date of service November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150, 87481, 87653, and 87641 billed for 
date of service November 28, 2022. 
 
You asked the Plan to pay for procedure code 87150, 87481, 87653, and 87641. You say that medical records 
were submitted. The Plan denied your request. The Plan says payment for code 87150, 87481, 87653, and 
87641 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The records show that a urinary tract infection panel test was provided. In this case, we have confirmed that 
codes 87481, 87653, and 87641 are column II codes to column I code 87801, and code 87150 is a column II 
code to column I code 87798. Codes 87150, 87481, 87653, and 87641 were billed with the XU modifier. The 
records do not show that the codes at issue were separate and distinct from the panel testing. 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 87150, 87481, 87653, and 87641 billed for date of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99219 billed for date of service September 
12, 2022. 
 
You asked the Plan to pay for procedure code 99219. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says provided records do not support the service 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 99219 is: Initial observation 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 physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes 
are spent at the bedside and on the patient's 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 procedure code 99219. Our reviewer says that procedure 
code 99219 does not meet criteria for payment. Our reviewer found that the medical records submitted did not 
indicate that the enrollee's status was designated or admitted for observation. Additionally, this initial 
observation evaluation and management code requires a comprehensive history, a comprehensive examination 
and medical decision making of moderate complexity. In this case, the medical records submitted did not 
support a comprehensive history. 
 
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 99219 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99219 billed for date of service September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis 
(specify substance or drug); initial, up to 1 hour (96365), intravenous infusion, for therapy, prophylaxis, or 
diagnosis (specify substance or drug); each additional hour (96366), refilling and maintenance of portable 
pump (96521) and insulin for administration through durable medical equipment (DME) (J1817) provided on 
January 27, 2023. 
 
You asked the Plan to pay for outpatient procedures. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed for codes 96365, 96366 and 96521 and code J1817 is not appropriate for the service 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. 
 
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 outpatient procedures. Our reviewer says that the service is 
not medically necessary. Our reviewer found that codes 96365 and 96366 are not supported. The 
documentation states that an insulin infusion was performed with monitoring of glucose levels and close 
supervision. There is a more specific code to report this service. Codes 96521 and J1817 are not supported. No 
DME pump was mentioned during this visit. An infusion pump was utilized to administer insulin in the office. 
There are more specific codes for the services reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient procedures have not been met. Therefore, we decided that the Plan 
does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or 
drug); initial, up to 1 hour (96365), intravenous infusion, for therapy, prophylaxis, or diagnosis (specify 
substance or drug); each additional hour (96366), refilling and maintenance of portable pump (96521) and 
insulin for administration through durable medical equipment (DME) (J1817) provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy injections provided 
from February 2, 2023, to February 16, 2023. 
 
You asked the Plan to waive the coinsurance for the injection drugs. You say that you disagree with the 
coinsurance 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 20% 
coinsurance for in-network chemotherapy drugs.  

You have been asked to pay $17.34, which is 20% coinsurance of the allowed amount for each injection 
provided on February 2, 2023, February 9, 2023, and February 16, 2023. The total amount you owe is $52.02 
($17.34 coinsurance x 3 injections = $52.02). These items/services fall within the Medicare Part B prescription 
drugs 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 the chemotherapy injections 
provided from February 2, 2023, to February 16, 2023.