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

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel of 51 or greater genes (81455) provided to the enrollee on January 20, 2022.
You asked the Plan to pay for these services. You say that this panel was medically necessary and reasonable for the management of the enrollee's advanced cancer. The Plan denied your request.
The Plan says that the results of this panel are unlikely to impact the therapeutic decision-making in the clinical management of this enrollee, and therefore these services are not medically necessary in this case.
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the specimen was collected. We looked at the file and Medicare rules. The file indicates that the DOS of the panel is not the same as the date the specimen was collected. 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 targeted genomic sequence analysis panel of 51 or greater genes (81455) provided to the enrollee on January 20, 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 IRF care is a medical necessity for the enrollee. 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 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 clinical documentation shows that the enrollee has active medical comorbidities; 
however, there are no complex functional deficits specified. The enrollee would not be expected to require intense therapy or interdisciplinary team management of rehabilitation in an IRF setting. The complexity of the 
enrollee's nursing, medical and rehabilitation documented needs would not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service July 
16, 2022. 
 
You asked the Plan to pay for the billed services. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the billed service cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment billed for date of service July 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is needed to help you 
breathe. You say that not having this device can cause other problems and put your life in danger. The Plan 
denied your request. The Plan says the records do not show that the noninvasive ventilator is to be used with 
settings that are any different from what can be supplied with a bi-level positive airway pressure (BiPAP) 
machine. The Plan says that the records do not show failure of BiPAP therapy. 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. This patient has a history of chronic obstructive pulmonary disease (COPD.) There are no pulmonary function tests to assess severity. There is a diagnosis of obesity-hypoventilation syndrome. The 
patient was recently admitted for decompensated heart failure, and arterial blood gasses (ABGs) were 
consistent with acute on chronic hypercarbic respiratory failure. The hospital notes indicate the patient needs 
BiPAP at night.  This patient would likely benefit from BiPAP during sleep.  BiPAP can provide the average 
volume-assured pressure support (AVAPS) mode if needed. 
 
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 12, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the testing billed with a date of service inconsistent with Medicare rules governing laboratory services. The records show the specimen was collected on November 29, 2021, rather than the billed date of service December 12, 2021. There is no documentation to support genetic testing on the billed date of service. Medicare Guidance states the date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim cannot be paid due to inconsistency with the dates of service and the date of specimen collection. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on December 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that the medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac joint arthrodesis provided to the enrollee on June 
10, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says they did not make a decision within the 60 day timeframe as required by Medicare. 
 
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 detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
diagnosis of sacroiliac dysfunction. There is no clear history of SI joint pain onset or failure of conservative 
treatment directed to the SI joint. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested sacroiliac joint arthrodesis provided on 6/10/21, in this case, was 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 sacroiliac joint arthrodesis provided to the enrollee on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75822 and 75825 billed for services 
provided on July 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were rendered in good faith. The 
Plan denied your request. The Plan says the codes are not supported in the documentation. 
 
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 looked at the file and the rules. The medical records provided do not show that the services billed with the -
59 modifier were a distinct procedural service. The records do not show that the services were performed on a 
different site of the body during the primary procedure. Based on this information, we decided that Medicare 
rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 75822 and 75825 billed for services provided on July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wrist joint arthroplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary 
osteoarthritis of the first carpometacarpal joint of the left hand. He presented with severe bilateral shoulder pain 
and severe basal joint pain of both thumbs. The exam reveals positive basal joint grind. The imaging is noted to 
show end-stage arthritis of the basal joint, left worse than right. However, detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. 
Additionally, there is limited published, large-scale, long-term peer-reviewed literature that shows this request 
to be an effective and/or safe treatment for the noted pathology. The services are therefore not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve wrist joint arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options is 
covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show that you are at 
high risk for a pressure ulcer, that you use intermittent catheterization for bladder management, or need a 
power seating system. The physical exam does not show reduced sensation that would lead to a pressure ulcer. 
You do not have a muscular or skeletal condition or a cast/brace that prevents 90 degree movement of the knee 
or significant swelling of the legs that requires elevating leg rests. The Group 3 PWC with multiple power 
options is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need a rehabilitation center to help you get 
stronger. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee can safely receive the services that they need at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an office visit for a consultation and a neuropathy 
exam provided on May 26, 2022. 
 
You asked the Plan to reimburse you for the office visit for a consultation and the neuropathy exam. You say 
that it is the Plans job to know all of the needed information to process your reimbursement request. The Plan 
denied your request. The Plan says the Plan cannot reimburse the services without substantial evidence to 
support the current procedural terminology (CPT) code and diagnosis code submitted under the direct 
reimbursement claim. Additionally, as the provider is not contracted with the Plan, the Plan has limited 
leverage to compel the provider to corporate in obtaining the information needed to process the members 
claim for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Medicare says the provider, supplier, or beneficiary, as appropriate, 
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of the office visit for a consultation and the neuropathy exam have 
been met. Specifically, you did not provide the Plan with the CPT and diagnosis codes. Therefore, we decided 
that the Plan does not have to reimburse you for an office visit for a consultation and a neuropathy exam 
provided on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99220. 
 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 99497 
is a column II code to column I code 99220. 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 procedure code 99497 billed for date of service May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 support surface. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 support surface is covered when 
specific criteria are met.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document that you 
have a history of or current pressure ulcer or myocutaneous flap or skin grafts. The criteria for coverage are not 
met and the requested Group 2 support surface is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 support surface.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show the enrollee had a 
caudal ESI on May 4, 2022 with 60 percent pain relief for one week and a repeat caudal ESI on August 18, 
2022 with 60 percent pain relief for one week. He did not have documented improvement in function. The 
enrollee did not receive at least 50 percent pain relief for three months from the prior injections; therefore, the 
repeat ESI is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided April 18, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are not 
contracted with the facility and are not notified that your product had been issued to the enrollee. The Plan 
denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep 
vein thrombosis during and/or following surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance 
(E0673) provided April 18, 2022.