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

We decided that the Plan does not have to pay for services provided to the enrollee on December 15, 2021 and billed under codes 77300, 77295, 77772, 77290 and 77334.
You asked the Plan to pay for code 77300. We note the Plan provided documentation to show codes 77295, 77771, 72290 and 77334 were reprocessed. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information to show the overturned codes were being reprocessed.
The Plan is correct in this case. 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, we have confirmed that code 77300 is a column II code to column I code 77771 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 the services described by procedure code 77300.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 10, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denial for 
reimbursement. You do not agree with the denial since these are routine laboratories that your specialist 
prescribed. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 10, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the comprehensive pharmacogenetics panel (8125, 81226) 
provided August 10, 2022. 
 
You asked the Plan to pay for  the genetic testing. You say that say the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the clinical value and 
effectiveness of comprehensive pharmacogenetics testing have not been demonstrated in the peer-reviewed 
literature.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for  
the comprehensive pharmacogenetics panel (8125, 81226) provided August 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 2, 2023, to 
January 12, 2023. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says a licensed 
professional counselor does not meet the criteria of a Medicare-qualified mental health care professional.  
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
January 2, 2023, to January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided on April 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99214 is not supported by the records provided. Our reviewer found that the documentation available for review does 
not support 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99214) provided on April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Registered Nurse 
First Assistant (RNFA) on August 4, 2022. 
 
You asked the Plan to pay for the RNFA services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says a RNFA is an ineligible provider type for 
Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Registered Nurse First Assistant (RNFA) on August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95955, 95927, 95908) provided on February 4, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 95955 is "Electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery)". The CPT Code Manual definition of code 95927 is "Short-
latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording 
from the central nervous system; in the trunk or head". 
 
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 services. Our reviewer says that the use of codes 95955 
and 95927 is not supported by the records provided. Our reviewer found that for code 95955, the record does 
not contain evidence that a diagnostic electroencephalogram (EEG) was performed during nonintracranial 
surgery. The record states that an EEG was used to assess the depth of anesthesia and for intraoperative 
monitoring. There is a more specific code for this service. For code 95927, the record does not contain 
evidence that short-latency somatosensory evoked potential (SSEP) studies in the trunk or head were 
performed. There is a more specific way to report the SSEP studies of the limbs. 
 
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 95955 and 95927 have not been met. 
 
In this case, we have also confirmed that code 95908 is a column II code to column I code 95861 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 the services 
(95955, 95927, 95908) provided on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 22, 2022, to 
February 24, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I50.33, described as 
Acute on chronic diastolic (congestive) heart failure. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does 
not support the billed code. Our physician reviewer found the documentation does not consistently and 
completely support the assigned secondary diagnosis code. The decision to remove the secondary diagnosis 
code and adjust the DRG is upheld. 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 22, 2022, to February 24, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional urinary catheter anchoring devices (A4333) 
and additional urinary drainage bags (A4358). 
 
You asked the Plan to pre-approve additional urinary catheter anchoring devices and urinary drainage bags. 
You say that the enrollee has a catheter and needs these supplies. The Plan denied your request. The Plan says 
urological supplies have limits for urinary catheter anchor devices and urinary leg bags that are covered. 
Coverage for urinary catheter anchor devices is 2 per month, and urinary leg bags are 3 per week. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for urological supplies have limits. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional urinary catheter anchoring devices and additional urinary drainage bags have not been 
met. Specifically, Medicare covers 2 urinary anchoring devices per month and 3 urinary leg bags per week. 
More than these amounts will be denied as not reasonably and necessary. Therefore, we decided that the Plan 
does not have to pre-approve additional urinary catheter anchoring devices (A4333) and additional urinary 
drainage bags (A4358).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 13, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this service should be covered at the in-
network rate. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot be safely discharged home. You require 
IRF services in order to return home independent. The Plan denied your request. The Plan says the request is 
not medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for January 31, 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 claim is not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for procedure code 99239 billed for January 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 15, 2022, to 
March 22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code E43, described as 
unspecified severe protein-calorie malnutrition. We asked our physician reviewer to carefully review the case 
file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 
the inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not 
support the billed code. Our physician reviewer found the enrollee is a 70-year-old male who was treated in the 
hospital. The documentation described the patient presenting with weakness, dyspnea, and diarrhea in the 
setting of rectal adenocarcinoma undergoing chemo/immunotherapy. His body mass index was 24.8 and weight 
of 187 pounds. His reported usual weight was 170-173 pounds. There was insufficient evidence of a weight 
loss of 10% or more over 6 months and he was not underweight to support the diagnosis of severe malnutrition.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 15, 2022, to March 22, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the requested Minuteman procedure 
is medically necessary. The Plan denied your request. The Plan says the requested Minuteman procedure is 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 the Minuteman procedure. Our 
reviewer says that the requested Minuteman procedure is not medically necessary. Our physician reviewer 
found the enrollee was being treated for intervertebral disc degeneration of the lumbar region. He presented 
with a history of axial low back that was treated with a NALU stimulation device. He began having worsening 
symptoms of neurogenic claudication and non-axial low back pain, and the device was removed. He has pain in the bilateral lower extremities, but his low back pain becomes much worse with activity. There is a limited 
lumbar range of motion with lumbar spinal tenderness noted. 
 
However, current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. 
 
According to the Food and Drug Administration (FDA), The Minuteman procedure is a posterior, non-pedicle 
supplemental fixation device, intended for use at a single level in the non-cervical spine (T1-S1). The 
Minuteman procedure is intended for use with bone graft material and is not intended for stand-alone use. In 
addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability have 
not been documented and/or met in this case. In addition, there are multiple alternate pain generators plausibly 
significantly contributing to the clinical condition that have not been fully documented as having been excluded 
and/or ruled out. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Minuteman procedure, in this case, 
is not medically reasonable or 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 the Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on October 26, 2022, billed 
with codes 87500, 87641, 87798, 8741, 87496, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653. 
 
You asked the Plan to pay for the laboratory testing billed. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. This panel was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on October 
26, 2022, billed with codes 87500, 87641, 87798, 8741, 87496, 87529, 87532, 87563, 87591, 87661, 87481, 
87651 and 87653.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) skin laceration 
repair services (12011)  closed treatment of proximal humeral (surgical or anatomical neck) fracture (23600) 
provided November 30, 2021. 
 
You asked the Plan to pay for the emergency services. You say that you request reconsideration of your claim 
for payment. The Plan denied your request. The Plan says additional information needed to process. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the emergency services have been met. 
additional records was requested from the provide. The Plan made multiple attempts to obtain the needed 
records from the provider without success.. Therefore, we decided that the Plan does not have to pay for the 
emergency department visit (99285) skin laceration repair services (12011)  closed treatment of proximal 
humeral (surgical or anatomical neck) fracture (23600) provided November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a continuous passive motion (CPM) exercise device 
(E0936). 
 
You asked the Plan to pre-approve a CPM exercise device. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the requested CPM device is covered if 
you have received a total knee replacement, and there is insufficient evidence to justify coverage of these 
devices for other applications. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve  a continuous passive motion (CPM) exercise device (E0936).