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

We decided that the Plan does not have to pay for the laboratory services (81455) provided to the enrollee on
April 12, 2022.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the specimen was collected during an
outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of
service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An
independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen
was not collected in an independent laboratory.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (81455)
provided to the enrollee on April 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided on November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Infuse BMP-2 Allograft (20931).
You asked the Plan to pre-approve Infuse BMP-2 Allograft. You say that this is medically necessary. The Plan
denied your request. The Plan says that the clinical value and effectiveness of the Infuse BMP-2 Allograft in
the setting of posterior lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature.
Our Medical director looked at the case file and the reopen request. At issues is coverage for Infuse BMP-2
Allograft. Our Medical Director states that there is evidence in the medical literature suggesting that the use of
BMP-2 allograft during lumbar spinal fusion procedures may aid bone fusion at similar or higher rates than
other bone graft materials. However, higher rates of adverse events are reported with the use of BMP-2
allograft. There is insufficient evidence supporting that the benefits of BMP-2 allograft use outweigh the risks
in lumbar spinal fusion. Our Medical Director found that your condition did not meet Medicare criteria for
Infuse BMP-2 Allograft.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Infuse BMP-2 Allograft have not been met. Therefore, we decided that the Plan
does not have to pre-approve Infuse BMP-2 Allograft (20931).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections to the lower back. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the chart says that there has only been 40-50% improvement with 
symptoms.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there have not been at least three months of moderate to severe pain that has not 
responded to conservative care. The previous injections only provided 40-50% improvement of symptoms. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections to the lower back.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found provided records document a 
diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records 
also document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-
up rate.  As stated in the LCD, claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 have a decrease in mobility in both legs, and 
your arm is broken with no feeling. You state that you are unable to return home without intensive 
rehabilitation. The Plan denied your request. The Plan says you do not have complex rehabilitation, medical, 
and nursing needs. Medically necessary treatment may be provided safely in a different level of care. 
 
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 enrollee returned to the hospital with a history of recurrent falls after discharge 
from an IRF for rehabilitation following a stroke. Her most recent fall resulted in a radial fracture. Her current 
status is requiring moderate assistance for transfers and daily living activities, which is a decline from her 
status after the stroke rehabilitation. 
 
The enrollee does not require intensive rehabilitation to restore function and address chronic falls. Her clinical 
course also demonstrated that she does not benefit from intensive rehabilitation. She does not have complex 
rehabilitation needs and does not require frequent physiatry oversight. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 15, 
2022. 
 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says not enough information was included. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there was no specific clinical rationale for the requested laboratory studies. The review 
has determined that the services at issue in this case were not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on August 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable automatic defibrillator. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a review of the clinical documents shows an ejection fraction of 30-35% in November 2022, less 
than 90 days after percutaneous revascularization. As such, you do not meet implant criteria for defibrillator 
insertion according to current guidelines. In the absence of such documentation, implantation of an automatic 
defibrillator would not be considered medically necessary in the management of this patient. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable automatic defibrillator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT heme comprehensive genomic profile panel (81455) provided to the enrollee on May 19, 2022.
You asked the Plan to pay for the panel. You say that this test was medically necessary and is supported in the medical record. The Plan denied your request. The Plan says that the specimen was collected during a hospital outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was collected in the hospital. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT heme comprehensive genomic profile panel (81455) provided to the enrollee on May 19, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for encephalopathy and urinary tract infection and was 
discharged home on January 19, 2023. There is ongoing weakness. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
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. 
There is not a reasonable expectation that the enrollee 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 pay for the additional critical care time provided on June 18, 2022, 
billed with 3 units of code 99292. 
 
You asked the Plan to pay for the three units of 99292. You say that the documentation did not include the 
evaluations provided by other physicians. These other consultations support the additional critical care time. 
The Plan denied your request. The Plan says the record only shows that the billing physician spent 75 minutes 
with the enrollee, which is reimbursed through the one unit of 99291. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that only providers of the 
same specialty in a group practice may bill as if they are a single physician. 
 
In this case, the CPT Code Manual definition of code 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient for each additional 30 minutes (list separately in addition to code for 
primary service). 
 
We find that three units of CPT code 99292 is not supported in the medical record. Specifically, while the 
progress notes show that other physicians (potentially of the same group practice) spent critical care time 
treating the enrollee, these providers were not of the same specialty as the billing provider on the claim at issue. 
Only the time spent by this provider (or the resident working under the billing provider) may be counted 
toward billable critical care time. Based on this information, we decided that Medicare rules for coverage of the 
three units of 99292 have not been met. Therefore, we decided that the Plan does not have to pay for the 
additional critical care time provided on June 18, 2022, billed with 3 units of code 99292.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0242U) provided on July 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and should be paid. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0242U) provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740) for teeth 20 and 
21. 
 
You asked the Plan to pre-approve the dental services. You say that it is necessary to have these crowns redone. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 21, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740) for 
teeth 20 and 21.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollees needs physical and occupational 
therapy services. You say that the enrollee remains at continued risk of decompensation. You say that the 
enrollee is at risk for falling and will benefit from an acute inpatient rehabilitation facility for close medical 
monitoring which can only be provided at this level of care. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for an emergency room visit. 
 
You asked the Plan to pay the full cost for an emergency room visit. You say that you should only be 
responsible for your copayment. The Plan denied your request. The Plan says the allowed amount for this 
service has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an emergency room visit have not been met. Specifically, the record indicates that the Plan has 
paid the Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed 
amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay the full cost for an 
emergency room visit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that these services were billed correctly and 
were medically necessary. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 19, 2022.