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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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.
There is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs. Based upon your current level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting. Our physician reviewer found that your 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 74018 provided on July 7, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. In this case, we have confirmed that code 74018 for the x-ray services is a column II code to column I code 74019.
This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 74018 provided on July 7, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87633, 87541, 87561, 87798, 87486, 87491, 87581, 87640, 87651, 87653) provided December 14, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. The records show this panel tested for 6 or more pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87633, 87541, 87561, 87798, 87486, 87491, 87581, 87640, 87651, 87653) provided December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92012), fluorescein angiography (92235), an electroretinography (92273) and eye photography (92285) provided on June 18, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for vision services. You say that you are asking for further reconsideration. You ask that we kindly reference the attached documents and re-process the claim accordingly. The Plan denied your request. The Plan says enrollees must use in network providers to get medical care and services. The Plan had network providers available to perform the services at issue.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an eye exam (92012), fluorescein angiography (92235), an electroretinography (92273) and eye photography (92285) provided on June 18, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Thoracentesis (32555) and Radiology examination (71045) provided on May 11, 2021.  You asked the Plan to pay for codes 32555 and 71045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the billing of duplicate claims.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the Plan does not have to pay for the Thoracentesis (32555) and Radiology examination (71045) provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2021.  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 there is no evidence of an established relationship between the member and the ordering physician.  The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.    The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses (L1971, L3170, L1851, L2397, L3960) provided
to the enrollee on February 24, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the orthoses (L1971, L3170,
L1851, L2397, L3960) provided to the enrollee on February 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on March 25, 2020.
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee's last day on hospice was March 11, 2020. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on March 11, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the visual field examination and gonioscopy provided on May 27, 2021.  You asked the Plan to pay for the visual field examination and gonioscopy. The Plan denied your request. The Plan says the billed services cannot be verified.  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 92082 is visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33). The CPT Code Manual definition of code 92020 is gonioscopy (separate 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 visual field examination and gonioscopy. Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the documentation does not include interpretation and report of an intermediate visual field examination, and therefore, CPT code 92082 cannot be confirmed. Our reviewer also says that the documentation does not include enough documentation to confirm the gonioscopy was performed. Therefore, CPT code 92020 cannot be verified as 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 visual field examination and gonioscopy have not been met. Therefore, we decided that the Plan does not have to pay for the visual field examination and gonioscopy provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the inpatient hospital services provided from May 14, 2021, to May 18, 2021.  You asked the Plan to pay for the inpatient care. You say that these services were medically necessary and provided medical records for review. The Plan denied your request. The Plan says medical records have not been provided to support the services or the medical records do not support the diagnosis or diagnoses as billed.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's denial rationale for both the claim and the appeal states that full medical records were not received to support the claim. However, the case file forwarded to us included medical records. It is unclear from the Plan's denial whether these records were not reviewed at the time of appeal or if there is a specific piece of information that is not supported in the record.    No medical review from the Plan was provided. Furthermore, the Plan has not made a cogent argument that any one of the specific diagnoses reported on the claim are not supported. Based on the language used by the Plan, it appears that there may be an unspecified issue with one of the secondary diagnoses submitted, of which there are seventeen. Maximus does not have jurisdiction to review an inpatient claim as a whole to determine if the correct diagnosis related group (DRG) was billed but can only independently review a Plan's determination regarding a specific component that is used in the DRG calculation. The exact reason for the denial in this case is unclear, whether the Plan finds that any aspect of this care was not medically necessary or if they found the specific DRG billed to be inappropriate. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from May 14, 2021, to May 18, 2021.   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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads, with interpretation and report (93010) provided July 29, 2021.
You asked the Plan to pay for the routine EKG. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is no coverage for EKG services when rendered as a screening test or as part of a routine examination. Enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 routine EKG. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had radiating pain down the left leg. There was no report of chest pain, shortness of breath or dizziness. The provided documentation did not support the ECG in this case as there was no acute issue warranting testing. It appears that this was for routine screening which is not supported by evidence and current guidelines. 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 routine EKG have not been met. Therefore, we decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads, with interpretation and report (93010) provided July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care provided from July 1, 2020, to July 9, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that the principal diagnosis code is supported. The Plan denied your request. The Plan says the billing of principal diagnosis code A41.9, Sepsis, unspecified organism, is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, unspecified organism. 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 an additional amount for the inpatient care. Our physician reviewer found while the enrollee presentation warranted consideration of sepsis, there was no evidence of life-threatening organ dysfunction due to dysregulated host response to infection. The reviewer found that There was no evidence of life-threatening organ dysfunction due to dysregulated host response to an infection, persistent hemodynamic instability or cognitive impairment that would be consistent with multi-system involvement due to specifically to sepsis. Therefore, the reviewer found that the records did not support the billing of principal diagnosis code A41.9, sepsis, unspecified organism. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care provided from July 1, 2020, to July 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage, for miles traveled beyond closest appropriate facility (A0888) provided September 23, 2019.
You asked the Plan to pay for the non-covered ambulance mileage. You say that the enrollee was found unresponsive and bleeding profusely and there was no way to get her to the hospital without the ambulance. The Plan denied your request. The Plan says requested medical records or trip notes from the ambulance service were not received verifying that coverage criteria was met.
The plan follows Medicare rules. The rules say that Medicare pays for air or ground ambulance services only if the enrollee's medical condition is such that transportation by means other than an ambulance would not be appropriate. The rules say that Medicare only pays for air or ground transport to the nearest facility that meets the enrollee's medical needs if the enrollee cannot be treated by the originating facility. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, for miles traveled beyond closest appropriate facility (A0888) provided September 23, 2019.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unattended sleep study (95800) provided on October 28, 2020.  You asked the Plan to pay for code 95800. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis.   We looked at the file and Medicare rules. Medicare provides limited coverage for code 95800. The diagnosis codes I10 and R40.0 are not covered diagnosis codes when billing code 95800 for payment. Therefore, we decided that the Plan does not have to pay for the unattended sleep study (95800) provided on October 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (77002) provided on April 21, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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, we have confirmed that code 77002 is a column II code to column I code 62323. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (77002) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99202) therapeutic exercises (97110) therapeutic activities (97530) electrical stimulation (G0283) chiropractic manipulation (98943) mechanical traction (97012) manual therapy techniques (97140) provided June 11, 2021 to June 23, 2021.
You asked the Plan to pay for the chiropractic services. You say that all of your doctors were on board that you seek any and all possible levels of comfort because you were losing mobility and it was imperative that you try to maintain whatever strength you could. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99202) therapeutic exercises (97110) therapeutic activities (97530) electrical stimulation (G0283) chiropractic manipulation (98943) mechanical traction (97012) manual therapy techniques (97140) provided June 11, 2021 to June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scaling in the presence of generalized moderate or severe gingival inflammation (D4346) provided on August 18, 2021.
You asked the Plan to pay for scaling in the presence of generalized moderate or severe gingival inflammation. You say that you were not informed the service was an exclusion, otherwise, you would have declined having the services performed. The Plan denied your request. The Plan says scaling in presence of generalized moderate of severe gingival inflammation is not listed as covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling in the presence of generalized moderate or severe gingival inflammation (D4346) provided on August 18, 2021.