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

We decided that the Plan does not have to pre-approve an Emerg AutoEmersion Therapy Mattress for the enrollee.
You asked the Plan to pre-approve an Emerg AutoEmersion Therapy Mattress. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the use of a group 2 support surface is only covered until the ulcer is healed.
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 an Emerg AutoEmersion Therapy Mattress. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The latest face to face examination of this enrollee reports his wounds are all fully healed, and he is on an appropriate support surface with caregivers instructed to use Z Guard to prevent breakdown and to turn the enrollee frequently. Given that the latest face to face examination documentation available to this reviewer reports the wounds are fully healed, approval for the Emerg AutoEmersion Therapy Mattress cannot be supported over the present support surface the enrollee is using. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an Emerg AutoEmersion Therapy Mattress.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Emerg AutoEmersion Therapy Mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve an Emerg AutoEmersion Therapy Mattress for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on May 7, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.
We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and
S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes.
Therefore, we decided that the Plan does not have to pay for the supplies rendered on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a walker purchased on the internet on April 1, 2021. 
 
You asked the Plan to pay for this walker. You say that this walker should be covered by the Plan for the 
enrollee. The Plan denied your request. The Plan says the online site the enrollee purchased the equipment from 
is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided by a practitioner who is not a Medicare eligible provider. This walker was 
purchased from a retail commercial internet provider who is not a Medicare eligible durable medical equipment 
provider. Therefore, we decided that the Plan does not have to pay for a walker purchased on the internet by the 
enrollee on April 1, 2021.
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 enrollee has received little therapy and struggled 
with pain since admission. The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for right total knee replacement. 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 patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a plastic 
surgeon on July 1, 2021. 
 
You asked the Plan to waive the copayment for the plastic surgery visit. You say that you had surgery on May 
28, 2021, and had your sutures removed on June 3, 2021.  You think that the follow-up visit on July 1, 2021, 
should be considered part of the surgical fee. The Plan denied your request. The Plan says you were charged 
this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for visits with a specialist.  
 
Medicare rules state that follow-up visits within the postoperative period are considered part of the global 
surgical package and are not separately payable.  Each surgery is assigned a postoperative period, which can be 
0 days, 10 days, or 90 days.  The surgery you had (procedure codes 11643 and 12051) has been assigned a 10-
day postoperative period.  Because the follow-up visit you had on July 1, 2021, falls outside of this 
postoperative period, a copayment can apply to this service. You have been asked to pay a $45 copayment for 
the plastic surgery visit. The plastic surgery visit falls within the visits with a specialist benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the office visit you had with a plastic surgeon on July 1, 
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 
29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you needed the 
ambulance transport due to a reaction from the Covid vaccine. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for each one-way ambulance transport.  
 
You have been asked to pay a $175 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transport provided on March 29, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from September 16, 
2019, through September 18, 2019, billed with principal diagnosis code J18.9 and secondary diagnosis code 
J96.01. 
 
You asked the Plan to pay for the inpatient services as billed. You say that the correct diagnosis codes were 
reported on this claim. DRG payment should not be reduced. The Plan denied your request. The Plan says the 
diagnoses were not supported. As such, the DRG payment made was not correct. 
 
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 J18.9, defined as 
pneumonia, unspecified, and secondary diagnosis code J96.01, defined as Acute respiratory failure with 
hypoxia. 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 inpatient services as billed. Our 
reviewer says that the records submitted do not support the two diagnoses reported on this claim. Our physician 
reviewer found the enrollee presented with cough and congestion with a prior diagnosis of pneumonia a week 
prior. Treatment with antibiotics was finished on day of admission. Chest x-ray did not show signs of 
pneumonia. The review indicates that there was no clinical indication of pneumonia or respiratory failure. The 
review has determined that the documentation did not support the reported principal diagnosis J18.9 
(Pneumonia, unspecified organism) for this inpatient admission. The documentation did not support the 
secondary diagnosis of J96.01 (Acute respiratory failure with hypoxia) for this admission.  
 
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 
for the inpatient hospital care provided from September 16, 2019, through September 18, 2019, billed with 
principal diagnosis code J18.9 and secondary diagnosis code J96.01.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services (75774-26-59 and 75726-26-59) provided on March 5, 2021.
You asked the Plan to pay for codes 75774-26-59 and 75726-26-59. You say that the medical records support the billing of codes 75774-26-59 and 75726-26-59 provided on March 5, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of codes 75774-26-59 and 75726-26-59 provided on March 5, 2021.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 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 codes 75774-26-59 and 75726-26-59.
Our reviewer says that the medical records do not support the billing of codes 75774-26-59 and 75726-26-59 provided on March 5, 2021. Our physician reviewer found the Centers for Medicare and Medicaid Services (CMS) has determined that code 37243 is appropriate for the procedure in this case and the radiologic supervision, interpretation, guidance and road-mapping of the procedure are included in the procedure and should not be reported and billed separately. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 75774-26-59 and 75726-26-59 have not been met. Therefore, we decided that the Plan does not have to pay for the angiography services (75774-26-59 and 75726-26-59) provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on May 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested. 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 pay for the definitive 
drug testing rendered on May 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care provided from 
April 24, 2021, to May 11, 2021. 
 
You asked the Plan to waive the copayment for inpatient mental health care. You say that you were overdosed 
and are unhappy with the quality of care you received. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $1,871 
copayment per stay for inpatient mental health care.  
 
You have been asked to pay a $1,871 copayment for inpatient mental health care. Inpatient mental health care 
falls within the inpatient mental health care benefit category.  

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient mental health care provided from April 24, 2021, 
to May 11, 2021.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on May 28, 2021.
You asked the Plan to pay for the testing services. You say that the services are eligible for payment. The Plan denied your request. The Plan says previous claims have met the maximum units for the time period.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code K0553 was billed and paid for by the Plan for date of service May 8, 2021. No more than 1 unit of service for code K0553 is billable per thirty days. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on May 28, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of an on-site home assessment that supports equipment 
use and access to maneuver the device. 
 
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 the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of any pressure injuries or requirement for intermittent catheterization of the bladder. The use of 
a group 3 power wheelchair would not be considered 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 15733 and 14060 are 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 15733 is muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae). The definition of code 14060 is adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less. We find that CPT codes 15733 and 14060 are not supported in the medical record. Specifically, there is no
documentation of muscle myocutaneous, or fasciocutaneous flap, from the head and neck with named vascular pedicle to support code 15733. There is no documentation of an adjacent tissue transfer or rearrangement of the eyelids, nose, ears, and/or lips for defects 10 sq cm or less to support code 14060. 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 pay for the surgical services rendered on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiology genetic panel (81225, 81226, 81227, 81230, 
81291, 81355, 81479) provided on March 15, 2021. 
 
You asked the Plan to pay for a cardiology genetic panel. You say that this is supported in the records. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a cardiology genetic panel 
have not been met. Therefore, we decided that the Plan does not have to pay for a cardiology genetic panel 
(81225, 81226, 81227, 81230, 81291, 81355, 81479) provided on March 15, 2021.
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 you can safely receive the services you need 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of
bilateral subdural hematomas. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 871 provided from May 21, 2020 to May 26, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of the principal diagnosis code A41.9: sepsis, unspecified organism with DRG 871. The Plan denied 
your request. The Plan says the medical records do not support the billing of the principal diagnosis code 
A41.9: sepsis, unspecified organism with DRG 871. 
 
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. 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 inpatient hospital services. Our reviewer says that the 
medical records do not support the billing of the principal diagnosis code A41.9: sepsis, unspecified organism 
with DRG 871. Our physician reviewer found the documentation indicates that the enrolllee was admitted with 
acute respiratory failure with hypercapnia. Labs revealed white blood count (WBC) 10.9 and Creatinine 1.44. 
He had transient hypotension. He was treated with IV fluids and supplemental oxygen. His condition stabilized 
and improved. There was no documentation of clinical sepsis. The review has determined that the records did 
not support the billing of DRG 871 with 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 
for the inpatient hospital services with diagnosis related group (DRG) 871 provided from May 21, 2020 to May 
26, 2020.