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

We decided the Plan does not have to provide coverage for a seat lift mechanism and recliner out of network.
You asked the Plan to provide coverage for this equipment. You say that this seat lift mechanism and chair are
medically necessary. The Plan denied your request. The Plan says this provider is out of network and does not
bill the seat lift mechanism and chair separately as is required by Medicare.
Maximus partially overturned the Plans denial stating the seat lift mechanism was medically necessary. The
Plan requested a reopen and stated the issue was not medical necessity but the fact that the provider being used
by the enrollee was not adhering to Medicare billing requirements. The Plan agrees the mechanism should be
covered however the recliner sold with the mechanism is not covered by Medicare. The Plan notes the enrollee
was directed back to a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare also does not
cover the recliner portion of a seat lift chair. The contract with the Plan says that the Plan has to pre-approve
care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that
cannot be provided by network providers.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide a seat lift mechanism that is appropriately billed. We found no exception that would require
the Plan to provide coverage for this equipment out of network. Therefore, we decided that the Plan does not
have to provide coverage for a seat lift mechanism and recliner out of network.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation provided on September 08, 2022. 
 
You asked the Plan to pay for electrical stimulation. You say that you believe the services are medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for electrical stimulation 
provided on September 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 5, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the physical therapist at a skilled nursing facility will 
not work with you and will end up laying around and be in there for a long period. The Plan denied your 
request. The Plan says your records do not show that you need an intensive team for your care. Services needed 
can be provided safely in other settings, at a skilled nursing facility, home with home health services or home 
with outpatient therapy.  
 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. 
 
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 pay for inpatient hospital services provided on November 1, 2022, to 
November 3, 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 these 
services and diagnoses were reported correctly. The Plan denied your request. The Plan says the diagnosis of 
acute and chronic respiratory failure with hypoxia (J96.21) is not supported in the medical record; therefore, 
the submitted DRG of 189 is not appropriate and is changed to 191. 
 
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 acute and chronic respiratory failure with hypoxia 
(J96.21). 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 this diagnosis is not sufficiently documented in the records 
provided. Our physician reviewer found that the record does not include documentation of blood gasses, 
although respiratory failure can be diagnosed with oxygen saturation (SpO2), medical record does not include 
sufficient supporting documentation to diagnose J96.21. The enrollee presented to the emergency department 
with complaints of dyspnea and cough. The enrollee has a history of chronic obstructive pulmonary disease 
(COPD). Per emergency department documentation, Oxygen saturation was 88% on room air and improved to 
100% with bronchodilator treatment and oxygen at 2L/min via nasal cannula. Emergency department 
documents "After being given a breathing treatment in route, the patient's oxygen saturation came up from 80% 
up to 95%". A day later, oxygen was discontinued, and oxygen saturation remained above 90%. Acute 
respiratory failure in the setting of a COPD exacerbation is characterized by worsening hypoxemia and often 
presents with variable degrees of carbon dioxide retention and acidemia. Hypoxemia probably results from 
worsening ventilation-perfusion (V/Q) mismatching, often with modest increases in shunt fraction. In this case, 
there is insufficient documentation to support J96.21 as a primary diagnosis.  
 
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 November 1, 2022, to November 3, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ketamine injection billed with code J3490 for date of 
service December 15, 2022. 
 
You asked the Plan to pay for the Ketamine injection. 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. 
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs.  
 
We find that CPT code J3490 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee received a Ketamine injection. The National Drug Code (NDC) included on the claim was not 
the accurate NDC for the drug provided.  
 Based on this information, we decided that Medicare rules for coverage of the Ketamine injection have not 
been met. Therefore, we decided that the Plan does not have to pay for the Ketamine injection billed with code 
J3490 for date of service December 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopy provided on February 09, 2023. 
 
You asked the Plan to pay for endoscopy. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for endoscopy provided on 
February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 for date of service December 19, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plans denial. The Plan 
denied your request. The Plan says the code is 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this code was billed with a 
primary diagnosis code of F09 (unspecified mental disorder due to known physiological condition). This 
diagnosis code has a code first note meaning that the underlying physiological condition must be coded first. 
Diagnosis F09 is not a valid primary code. This code is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99232 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99232 for date of service December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 2, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a crown (D2740) and core buildup (D2950) 
for tooth #3 provided on April 4, 2022. 
 You asked the Plan to waive the copayment for the dental services. You say that you believe the dental office 
overcharged the enrollee and you would like to appeal the dental services. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. Also, the enrollee is responsible for the fees associated for 
the upgraded service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for a crown and a $42 copayment for the core buildup The contract also says that 
providers are required to explain covered benefits as well as any elective differences in materials and fees prior 
to providing an elective upgraded procedure.  
 
The enrollee has been asked to pay a $250 copayment for the crown and a $42 copayment for the core buildup. 
The enrollee has also been asked to pay for the upgraded dental service. This item/service falls within the for 
the crown and the core buildup benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
crown (D2740) and core buildup (D2950) for tooth #3 provided on April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomies. 
 
You asked the Plan to pre-approve the stab phlebectomies.. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments for symptomatic varicose tributaries are 
either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy.  
 
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 stab phlebectomies. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the patient has not yet 
undergone saphenous vein reflux treatment. 
 
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 stab phlebectomies. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 8, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a covered service and this claim 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on October 06, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on October 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from August 17, 2022, to September 6, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this is a medical necessity 
appeal based on medical literature and the efficacy of the treatment rendered. The Plan denied your request. 
The Plan says this service does not meet the requirement of the enrollee's plan of benefits and is excluded from 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided from August 17, 2022, to 
September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on December 16, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 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 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 are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the file shows that the 
enrollee was admitted as an outpatient on the date of service at issue in this appeal. Code 99222 is an inpatient 
code. Based on this information, we decided that Medicare rules for coverage of procedure code 99222 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99222 provided on 
December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lightweight wheelchair provided on October 21, 2022. 
 
You asked the Plan to pay for a lightweight wheelchair. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a lightweight wheelchair 
provided on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 15, 2022, to December 
16, 2022. 
 
You asked the Plan to pay for office visit. You say that you believe the services are medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
November 15, 2022, to December 16, 2022.