Persius/hicric huggingface dataset:
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 IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like to use this provider. The 
Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physician services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has type II diabetes. The Plan 
denied your request. The Plan says the services are available from the preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred DME 
providers. 
 
We looked at the file and Medicare rules. The requested services are OneTouch test strips. OneTouch is not the 
preferred provider for diabetic supplies with the Plan. Diabetic testing supplies are available from the preferred 
provider, Accu-Chek. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue 
test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PCR Urinary Tract Infection panel (87799, 87798, 87482) 
provided September 28, 2020. 
 
You asked the Plan to pay for the PCR Urinary Tract Infection panel. You say that the services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 pay for the PCR Urinary Tract Infection panel. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the standard of care is urinalysis with urine culture and sensitivity. As such, the 
PCR testing is considered unproven and not medically necessary. PCR amplification techniques raise 
considerable concerns regarding contamination from one specimen to another, creating the potential for false-
positive results. 
 
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 PCR Urinary Tract Infection panel have not been met. Therefore, we 
decided that the Plan does not have to pay for a PCR Urinary Tract Infection panel (87799, 87798, 87482) 
provided September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires, per pair (A4557) provided September 28, 2020 
 
You asked the Plan to pay for the lead wires. You say that Per CMS LCD L33802, A4557 is not inclusive to 
A4595 and is separately reimbursable. There is no documentation indicating that A4557 and A4595 cannot be 
billed with the same service date. The Plan denied your request. The Plan says a TENS unit had been purchased 
in the previous 12 months, therefore the lead wires is not covered. Records supporting additional lead wires 
were not submitted. 
 
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 lead wires have not been met. Therefore, we decided that the Plan does not have to pay for lead 
wires, per pair (A4557) provided September 28, 2020
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician 
evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from September 8, 2020, 
through  
September 15, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that, in 
most cases, care you receive from an out-of-network provider will not be covered. If you need medical care 
that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get 
this care from an out-of-network provider. 
 
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 services provided from 
September 8, 2020, through September 15, 2020.
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 IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 he complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on March 8, 2020 to 
March 10, 2020. 
 
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 a different DRG would be more accurate. 
 
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. DRG 871 is defined as "septicemia 
or severe sepsis without MV > 96 hours with MCC."  
 
In this case, you billed the services provided March 8, 2020 to March 10, 2020 with DRG 871. 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our physician reviewer found the review indicates that the 
enrollee presented to the ER with fever, leukocytosis, elevated lactate, and multifocal pneumonia. There was no 
hemodynamic instability. Fluid repletion was necessary without pressor support. There was no evidence for 
multi-system organ damage. The review has determined that DRG, A41.9 Sepsis, unspecified organism, 
R65.21 Severe sepsis with septic shock, and E43 Unspecified severe protein-calorie malnutrition were not 
supported by the clinical records and/or did not impact the clinical resource utilization. The review indicates 
that the correct DRG (871 - septicemia or severe sepsis without MV > 96 hours with MCC) was used in this 
admission. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
inpatient hospital services provided to the enrollee on March 8, 2020 to March 10, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiomyopathy (81439), noonan spectrum 
disorders (81442), molecular pathology procedure, Level 7 (81406), and molecular pathology procedure, Level 
8 (81407) provided on May 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for hereditary cardiomyopathy, noonan spectrum disorders, molecular pathology 
procedure, Level 7, and molecular pathology procedure, Level 8. You say that the services were provided and 
payment should be rendered. The Plan denied your request. The Plan says there were in-network providers that 
were able to provide this care. Therefore, coverage criteria has not been met. 
 
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 hereditary cardiomyopathy (81439), noonan 
spectrum disorders (81442), molecular pathology procedure, Level 7 (81406), and molecular pathology 
procedure, Level 8 (81407) provided on May 8, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 a power wheelchair. Our reviewer says 
that the documentation does not support that the requested power wheelchair is medically reasonable or 
necessary. Our physician reviewer found the documentation does support that you have a personal mobility  
deficit but this deficit currently does not impair participation in mobility related activities of daily living in the 
home. Your mobility deficit is currently helped by a manual wheelchair. According to the physical therapy 
assessment that was completed on November 19, 2020, you receive outside support for all your activities of 
daily living/instrumental activities of daily living needs. In addition, your home is not accessible from any 
entrance and ramps are not an option. The documentation does not support that the requested Group 2 power 
wheelchair will significantly improve your participation in mobility related activities of daily living in the 
home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on January 31,
2020 and billed under the above-mentioned claim.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says that this claim denied because this
service was included in the allowance for another service and is not allowed to be paid separately when a
transitional care management services has already been allowed 30 calendar days prior to the date of service
being billed.
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 codes and within the appropriate
guidelines set by Medicare. Based on the claim information provided, the second claim cannot be paid
separately due to a previously paid claim and its bundled relation to that service. Medicare rules for coverage
of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health
services provided to the enrollee on January 31, 2020.
Appeal type: Imaging
Decision: Favorable

We decided the Plan does not have to pay forphysician services provided to the enrollee on March 10, 2020. You asked the Plan to pay forphysician services provided to the enrollee. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The claim in question denied because the Plan previously paid for this service under another claim, as stated above. The Plan states that their records show this service was paid to the same provider under a different claim. Both claims reported the same modifier, therefore there was nothing indicating the second claim was a separate and distinct service. 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 codes. In this case, the second claim billed appears to be identical to a claim already paid and therefore cannot be paid as billed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay the second claim submitted forphysician services provided to the enrollee on March 10, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay the second claim submitted for physician services provided to
the enrollee on April 14, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information regarding the claims in question.
The Plan states that this claim denied because the provider did not bill this service with the appropriate
modifier. The Plan shows code 71045 was billed with modifier 26, but this was incorrect. The provider needed
to bill with modifier 59 to show as a separate encounter per Medicare billing guidelines. The Plan states this
service was previously paid for this enrollee on the same date of service.
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 codes and when required the
appropriate modifiers. In this case, this claim cannot be paid as billed due to the omission of a modifier to show
this was a separate and distinct service from the claim previously billed and paid. Medicare billing criteria are
not met. Therefore, we decided that the Plan does not have to pay for a second claim submitted for physician
services provided to the enrollee on April 14, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay fordrug testing provided to the enrollee on August 9, 2019 and billed under code G0481.You asked the Plan to pay forthis testing. You say that this claim should be paid.The Plandenied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that denied because this service does not meet the criteria for the category under which it was billed. After clinical review of the medical records, the service was determined to be coded incorrectly. This is a billing error on the part of the providerand is not reimbursable. The Plan states the records do not showdocumentationofdefinitivelaboratoryresultsfor8-14  drug  classes, including  metabolitesto support code G0481. 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 denial is based on a coding error and not a medical necessity error. The documentation provided does not support the category of testing billed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee on August 9, 2019 and billed under code G0481
Appeal type: Imaging
Decision: Favorable

We decided the Plan does not have to pay for physician services provided to the enrollee on April 25, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says this claim denied because the provider
billed with an inappropriate modifier. The records show code 73502 was billed with modifier 26, but this was
incorrect. The Plan says that provider needed to bill with modifier 59 to show this was a separate encounter in
order for payment to be processed. The records show this claim was previously paid to another provider of the
same practice group; therefore, the second claim cannot be paid based on the omission of the 59 modifiers.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate
and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for physician services provided to the enrollee on April 25, 2020.