Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99291 provided March 31, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the service is not supported by the records. 
 
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does meet criteria. The physician documentation describes, 45 minutes were spent with 
critical care service, treating or preventing imminent or life-threatening deterioration. Cardiac output 
measurements, and reviewing radiology, oxygen levels, laboratory services with evaluations and re-
evaluations. In this case, this procedure should be covered. 
 
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 service have been met. Therefore, we decided that the Plan has to pay for 
code 99291 provided March 31, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connection device for a Group 3 power wheelchair. 
 
You asked the Plan to pre-approve expandable controller components. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the records do not show a medical need to 
control power options through a joystick. 
 
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 expandable controller components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has adequate strength to manage the wheelchair's standard 
power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller, harness, and electronic connection device 
for a Group 3 power wheelchair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28510 for date of service November 27, 
2022. 
 
You asked the Plan to pay for procedure code 28510. 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 28510 is closed treatment of fracture, phalanx or 
phalanges, other than great toe; without manipulation, each. 
 
We find that CPT code 28510 is not payable as billed. Specifically, this code was not billed with an anatomical 
modifier appended. Providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1- T9, 
E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. Based on 
this information, we decided that Medicare rules for coverage of procedure code 28510 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 28510 for date of service 
November 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652 and a segmental trunk appliance. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0652 PCD is covered when specific criteria 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found that you have a medical history of breast 
cancer and are noted to have lymphedema (swelling) of the left arm. There is no documentation of what types 
of conservative treatments have been attempted, including compression garments and lymphedema treatment. 
There are no provided measurements. You do not have lymphedema extending to the trunk. The criteria for 
coverage are not met; therefore, the PCD and trunk appliance are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) described by code E0652 and a segmental trunk 
appliance.
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 you need this to return to prior level of function. The 
Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, 
your needs can be safely provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate setting.  
 
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 at-home virtual pulmonary rehabilitation. 
 
You asked the Plan to pre-approve pulmonary rehabilitation. You say that the enrollee's medical history and 
mental health are barriers to leaving the home without taxing effort. The Plan denied your request. The Plan 
says pulmonary rehabilitation is only covered in a physicians office or a hospital outpatient setting. 
 
The Plan must follow Medicare rules. Medicare rules say that pulmonary rehabilitation must be provided in a 
physicians office or outpatient hospital setting in order to be covered. A home setting lacks both a hands-on 
physician and the necessary equipment available in a medical setting and is therefore not covered.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Pulmonary Rehabilitation have not been met. Therefore, we decided that the Plan does not have to 
pre-approve at-home virtual pulmonary rehabilitation.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve stab phlebectomy of varicose veins, 1 extremity; 10-20 stab 
incisions (37765). 
 
You asked the Plan to pre-approve stab phlebectomy of varicose veins. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will consider invasive procedures (only 
with the techniques outlined in this local coverage determination (LCD) and under the conditions described) as 
reasonable and necessary when documentation in the medical record includes a history, physical examination, 
CEAP clinical classification, and a venous duplex scan documenting reflux (>500 msec). 
 
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 stab phlebectomy of varicose veins. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the documentation provided satisfies criteria requiring documentation of Clinical (C), Etiological (E), Anatomical (A), and 
Pathophysiological (P) (CEAP) scoring. There is satisfactory documentation to satisfy the CEAP scoring 
requirement. All coverage criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy of varicose veins have been met. Therefore, we decided that 
the Plan has to pre-approve stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions (37765).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the inpatient rehabilitation facility is the best 
treatment option for you based on your medical state. The Plan denied your request. The Plan says that you do 
not meet the requirements for IRF admission.  
 
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 the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in  and benefit from  the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker provided to the enrollee on January 9, 2023.

You asked the Plan to pay for this claim. You say that the Plan denied this claim in error. The Plan denied your
request. The Plan says the claim did not have the required KX modifier. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code and when necessary, the appropriate modifier.
In this case, this walker required a KX modifier on the claim per the LCD. Medicare rules for payment of this
claim have not been met. Therefore, we decided that the Plan does not have to pay for a walker provided to the
enrollee on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 to pre-approve. Our reviewer says that 
the requested ILR procedure is not medically reasonable and necessary based on NCD criteria. Our physician 
reviewer found based on current guidelines and the documentation provided, there is insufficient clinical 
evidence to support the medical appropriateness and necessity of replacing the enrollee's old ILR with a new 
ILR. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are requesting reconsideration and 
have submitted medical records for review. The Plan denied your request. The Plan says the records sent do not 
support the request for treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have chronic back pain with little response to therapy. You have a 
home exercise program. The record does not support continued therapy based on response to prior therapy per 
chapter 15 section 220.2 as there is not a medical necessity for continued unique input from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine (9) physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot brace (L1971), provided on July 5, 2023. 
 
You asked the Plan to pay for the ankle foot brace. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was needed, discussed or ordered in the clinical records submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the ankle foot brace (L1971), provided on July 5, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99487 and 94489 provided June 30, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 99487 is complex chronic care management services with 
the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, 
or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored, moderate or high complexity medical decision making; first 60 minutes of clinical staff 
time directed by a physician or other qualified health care professional, per calendar month.  
The definition of code 99489 is complex chronic care management services with the following required 
elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the 
patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored, moderate or high complexity medical decision making; each additional 30 minutes of 
clinical staff time directed by a physician or other qualified health care professional, per calendar month (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 services. Our reviewer found no documentation 
supporting the services in question was submitted. These services cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99487 and 94489 provided June 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the provider referred the enrollee for the 
service rendered due to medical necessity. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes.  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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service July 16, 2023, to August 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services (99285) provided on April 27, 2023. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making". 
 
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 99285 is not supported by the records provided. Our reviewer found that the enrollee is a 60-year-old male who 
presented to the emergency department (ED) with report of having dizzy episodes and loss of consciousness 
but no other injury, similar to multiple prior ED visits in the prior month. He was given intravenous (IV) fluids, 
and workup including computed tomography angiography (CTA) were negative for acute disease. Vitals were 
stable. The plan was to follow-up with primary care physician. Based on the provided documentation for this 
encounter, there was insufficient support for a high level of medical decision-making to justify code 99285. 
 
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 emergency services (99285) provided on April 27, 2023.