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

We decided the Plan does not have to provide coverage for a Contour Next One meter and test strips.

You asked the Plan to provide coverage for a Contour Next One meter and test strips. The Plan denied your
request. The Plan says a Contour Next One meter and test strips are not a preferred brand covered by the Plan.
Maximus overturned the Plans denial for a lack of contract information in the case file confirming this
information. The Plan requested a reopen and provided the annual notice of change informing enrollees of this
requirement.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
coverage information. The contract with the Plan clearly says that enrollees must use specific a brand of
diabetic supplies. A Contour Next One meter and test strips is not one of the Plans required brands. Therefore,
we decided that the Plan does not have to provide coverage for a Contour Next One meter and test strips for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code J3490 billed to the enrollee for October 10, 2022.

You asked the Plan to pay for this claim. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct billing criteria. The Plan noted that payment for local anesthetic is included
in the payment for the injection and infusion services and cannot be billed separately.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, code J3490 was billed separately in error. Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for procedure code
J3490 billed to the enrollee for date of service October 10, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 96365 and 96366. We decided that the Plan does not 
have to pay for code 96521.  
 
You asked the Plan to pay for the intravenous (IV) infusion services (96365, 96366, 96521) provided July 27, 
2023. You say that the claim should be paid. The Plan says that the services are not supported by the records. 
 
 
 We decided that the Plan has to pay for procedure codes 96365 and 96366.  
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). 
 
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 item/service at issue. Our reviewer says that the 
documentation supports that 96365 and 96366 were provided. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for procedure codes 96365 and 96366.  
 
We also decided that the Plan does not have to pay for code 96521. 
 
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 96521 is refilling and maintenance of portable pump. 
 
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 item/service at issue. Our reviewer says that the 
documentation does not specifically document that code 96521 how and if was performed. 
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for code 96521. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s) 
(64635). 
 
You asked the Plan to pre-approve the radiofrequency ablation (RFA). You say that this case was previously 
approved. You say you needed to extend the date range as you were not able to get the enrollee scheduled 
before the dates expired. The Plan denied your request. The Plan says that the request is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is covered when the criteria listed in the 
Medicare rules section are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the radiofrequency ablation (RFA). Our 
reviewer says that the service is medically necessary. Our physician reviewer found the LCD states if there is 
an extended time, two years or more, since the last RFA and/or there is a question as to the source of the 
recurrent pain then diagnostic procedures must be repeated. There is no question of the source of the pain in the 
enrollee. The request is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiofrequency ablation (RFA) have been met. Therefore, we decided that 
the Plan has to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s) (64635).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria per CMS guidelines. The Plan denied your request. The Plan says criteria for admission to 
the LTACH have not been met. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH is 
not medically 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99354 billed for dates of service January 4, 2023, to 
January 13, 2023. 
 
You asked the Plan to pay for cod 99354. The Plan denied your request. The Plan says this is not a valid code. 
 
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 find that payment for CPT code 99354 is not supported. Specifically, code 99354 is not a valid code for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of cod 99354 have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99354 billed for dates of 
service January 4, 2023, to January 13, 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 request is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility services 
requested do not meet the requirements for approval.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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 pre-approve a platelet rich plasma injection (0232T). 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that the injection is crucial for 
ensuring continuity in your treatment plan. The Plan denied your request. The Plan says the requested service is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the existing evidence and lack of accepted 
standards of medical practice for platelet rich plasma (PRP) injections do not meet the requirement of 
medically reasonable and necessary. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a platelet rich plasma injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a platelet rich plasma injection (0232T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy. 
 
You asked the Plan to pre-approve high dose rate electronic brachytherapy. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says there is no good data to support the safety or use of 
electronic brachytherapy for skin cancer. It is not generally accepted for this condition. 
 
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 high dose rate electronic brachytherapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a 83-year-old male with right nasal dorsum basal cell carcinoma. He had a shave biopsy from the right nasal dorsum on September 8, 2023, which confirmed basal 
cell carcinoma, focally infiltrating pattern. The enrollee was seen in consultation and electronic brachytherapy 
with surface application per fraction was recommended (10 fractions). 
 
There is still limited data in regard to the risks versus benefits, efficacy, and safety of electronic brachytherapy 
(EBT) in the treatment of early-stage non-melanoma skin cancers (NMSC). Few non-randomized retrospective 
studies/case series showed that EBT is an effective and safe treatment option for NMSC. These studies did not 
define the optimal course of electronic brachytherapy. Moreover, long-term follow-up results are needed to 
know a) the durability of response to electronic brachytherapy (recurrence rate) and the need for additional 
treatments or repeat electronic brachytherapy or other local therapies, and b) the late side effects. 
 
Due to limited available good quality data and lack of level I evidence, the decision to treat early-stage NMSC 
with electronic brachytherapy and duration of treatment is still a clinical equipoise. Therefore, electronic 
brachytherapy is not considered medically necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high dose rate electronic brachytherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93005, 94761) provided on May 11, 2023.  
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
packaged and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
The rules also say that services with status indicator N are paid under the OPPS, but their payment is packaged 
into payment for a separately paid service. 
 
We looked at the file and Medicare rules. In this case, code 93005 is assigned a Q1 indicator, which means this 
code is not payable when another service with status indicator S, T, or V, is reported on the same claim. As 
code 99285 is assigned a status indicator V, code 93005 is not payable. Additionally, code 94761 is assigned 
status indicator N under OPPS, which means this code is packaged and is not separately payable. 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 (93005, 94761) provided on May 11, 2023.
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 November 
14, 2022. 
 
You asked the Plan to pay for procedure code 99100. 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 November 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99203-25 rendered on May 18, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records did not show a significant and separately identifiable evaluation and 
management service unrelated to the decision to perform the minor surgical 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, the CPT Code Manual definition of 
code 99203 is "Office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and low level of medical decision making. When 
using time for code selection, 30-44 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 services at issue in 
this case were supported by the medical records. Our reviewer found that the provider reported CPT 99203 
with modifier 25 bypass the edit with the knee injection procedure performed on the same date of service. The 
procedure report describes that the enrollee presented with bilateral knee pain. This was an initial visit for the 
problem addressed. An assessment was performed, including right and left knee x-rays to evaluate for pain and 
instability. Education was provided for arthritis and pain, and an injection was given. In this case, the provider 
performed an initial assessment on the bilateral knees, and a decision was made for injection after the enrollee 
was educated. This procedure and the modifier should be covered, in addition to the injection service provided. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 99203-25 rendered on May 18, 2023.  
 
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 the electroencephalogram (EEG) during nonintracranial
surgery (95955) provided to the enrollee on November 8, 2022.

You asked the Plan to pay for the EEG. You say that the service should be paid. The Plan denied your request.
The Plan says that the service was not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an EEG. Our
Medical Director states that the documentation is insufficient to demonstrate that intraoperative EEG
monitoring was medically reasonable and necessary for the enrollee in this case. Our Medical Director found
that the enrollee's condition did not meet criteria for coverage of the EEG.

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 EEG have not been met. Therefore, we decided that the Plan does not have
to pay for the electroencephalogram (EEG) during nonintracranial surgery (95955) provided to the enrollee on
November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99213) 
rendered on June 14, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says it would not be medically necessary or appropriate to bill a higher level of evaluation and 
management services when a lower level of service is warranted. 
 
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 99213 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 low level of medical decision making. When using time for code selection, 20-29 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support 20-29 minutes of total time spent and the documentation is more consistent with straightforward 
medical decision-making, rather than low level. 
 
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 evaluation and management services (procedure code 99213) rendered on June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service February 15, 
2023.   
You asked the Plan to pay for procedure code 88374. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service February 15, 2023.