Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested IRF admission 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 that the complexity of the enrollees 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 infection of the knee joint. The enrollees medical problems are stable. There are 
no complex nursing or rehabilitation needs. While the enrollee may have 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve an inpatient psychiatric hospitalization. You say that an inpatient admission 
is medically necessary The Plan denied your request. The Plan says this admission has been correctly denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospitalization. 
Our reviewer says that the medical criteria for an inpatient psychiatric hospital stay have not been met. Our physician reviewer found the admission of this enrollee does not meet criteria for acute inpatient mental health 
treatment as this enrollee was not shown to be a danger to himself or others, no auditory or visual 
hallucinations. He is noted to be cooperative and compliant with treatment while not showing any aggressive 
behaviors. 
 
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 inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on May 5, 2022.
You asked the Plan to pay for the laboratory services. You say that this should be paid for. The Plan denied
your request. The Plan says that there is no documentation that the sample was actually taken in the laboratory.
Maximus overturned the Plan's 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
provided to the enrollee on May 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested IRF admission 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 that the complexity of the enrollees 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 thoracic spine fusion. The enrollees 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 enrollee may have 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to receive the medical care 
needed at a lower level of care. You say the enrollee needs physical therapy, insulin, medications 
administration and assistance with incontinence and hygiene. The Plan denied your request. The Plan says 
based on Medicare guidelines, the SNF services requested do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee may require skilled therapy 
services that require the specialized skill, knowledge, and judgment of a skilled professional therapist, but no 
formal evaluations with physical or occupational therapy with regard to the enrollee's needs with mobility, 
transfers and activities of daily living have been documented. The enrollee reportedly has refused to follow 
through on a recommended exercise program at home. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Records are inadequate to 
document a significant decline in the enrollees functional status compared to their recent baseline to 
necessitate daily inpatient skilled therapy services. Records are inadequate to show that services in the home 
with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 30, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. 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 office visit provided on 
August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99360 and A4215 billed for date of service 
September 1, 2022. 
 
You asked the Plan to pay for procedure codes 99360 and A4215. You say that these services were medically 
necessary and were reported correctly. The Plan denied your request. The Plan says these services are not 
payable as billed and may only be paid to the facility under Part A. 
 
The Plan must follow Medicare rules. Medicare rules say that standby services (code 99360) are not payable to 
or billable by physicians. Payment for this service is included in the hospital facility payment. The rules also 
say that submitted claims in which the unit of service exceeds the MUE value cannot be paid when the MAI 
value is 3, unless there is evidence justifying the excess units. 
 
We looked at the file and Medicare rules. In this case, code 99360 was billed by a physician. This code cannot 
be paid to a physician. In addition, the MUE for CPT code A4215 is 9. The MAI value for this code is 3. You 
billed 18 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the 
excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99360 and A4215 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99360 and A4215 billed for 
date of service September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-radiological diagnostic services 
provided on September 14, 2022. 
 
You asked the Plan to waive the copayment for non-radiological diagnostic services. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $25 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $25 copayment for non-radiological diagnostic services. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 non-radiological diagnostic services provided on September 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vitamin D (82306), thyroxine (84439), and thyroid 
stimulating hormone (TSH) (84443) testing provided on July 13, 2022. 
 
You asked the Plan to pre-approve vitamin d, thyroxine and TSH testing. You say that these tests were 
medically necessary. The Plan denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, vitamin d, thyroxine and TSH testing, is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pre-approve vitamin D (82306), thyroxine (84439), and thyroid stimulating hormone (TSH) 
(84443) testing provided on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme testing provided to the enrollee on
January 7, 2022.
You asked the Plan to pay for the FoundationOne Heme testing. You say that the testing was medically
necessary. The Plan denied your request. The Plan says that the sample was not taken by the laboratory
directly.
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 FoundationOne Heme
testing provided to the enrollee on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97598, 97597, and 99291 billed for date of 
service February 21, 2022, to February 25, 2022. 
 
You asked the Plan to pay for procedure codes 97598, 97597, and 99291. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 97598, 97597, and 99291 is 
bundled into payment for codes 11403 and 11406. 
 
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 codes 
97598, 97597, and 99291 are column II codes to column I codes 11403 and 11406. While code 97598 was 
billed with modifier -59, the documentation does not support that this procedure was distinct or independent 
from the other services performed. 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 codes 97598, 97597, and 99291 billed for date of service February 21, 
2022, to February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a segmental pneumatic appliance for use with pneumatic compressor, chest (E0657).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that medical records have been submitted for review of the denial. The Plan denied your request. The Plan says the requested device and appliance is not medically necessary. The enrollee has lymphedema of the neck on physical examination. The provider does not document lymphedema of an extremity extending onto the chest, trunk and/or abdomen. The enrollee underwent one documented treatment with a head and trunk pneumatic pump during one session for thirty-two (32) minutes on December 5, 2022, after which the physical therapy provider recommended a "home pneumatic pump unit".

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a segmental pneumatic appliance for use with pneumatic compressor, chest (E0657).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene panel testing provided to the enrollee on March 18, 2022.
You asked the Plan to pay for the testing services. You say that the testing provides possible treatment options. The Plan denied your request. The Plan says that the specimen was collected in the hospital.
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 gene panel testing provided to the enrollee on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 29, 2022.
You asked the Plan to pay for this testing. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that this is an administrative determination for billing and is not based on clinical criteria for medical necessity. 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. The specimen was collected during a hospital outpatient encounter, not by the independent lab. The claim was also billed without the unique test identifier or DEX Z Code.
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 could not be paid due to errors with the POS code reported and the omission of the required test identifier code. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an SNF admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.