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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options, power seat elevation system and upgraded electronics coded as K0861, E2361, E1028, E2377, E2313, 
E2300, E2311, E2620, E0955, K0038, K0040, E0956, E2607 
 
You asked the Plan to pre-approve a power wheelchair. You say that please reconsider the denial as the 
enrollee is needing this power wheelchair and accessories to function day to day. The Plan denied your request. 
The Plan says the enrollee does not have medical need for multiple power options included with K0861 group 
3 power wheelchair. E2300 does not serve a medical purpose and cannot be approved. 
 The Plan follows Medicare rules The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 power wheelchair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not use a ventilator or intermittent catheterization and is not at high 
risk for skin breakdown. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 3 power wheelchair with multiple power options, power seat elevation system 
and upgraded electronics coded as K0861, E2361, E1028, E2377, E2313, E2300, E2311, E2620, E0955, 
K0038, K0040, E0956, E2607
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 29, 2021, to 
June 13, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical record supports the diagnosis as billed. The Plan denied your request. The Plan says the secondary 
diagnosis of N17.0 (acute kidney failure with tubular necrosis) is not supported in the medical record. Rather, 
the secondary diagnosis should be N17.9 (acute kidney failure, unspecified.) The medical records do not 
support tubular necrosis. 
 
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 the secondary diagnosis of N17.0 (acute kidney 
failure with tubular necrosis). 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 at the DRG originally billed. Our reviewer says that the secondary diagnosis of N17.0 (acute 
kidney failure with tubular necrosis) is not supported in the medical record. Our physician reviewer found the 
patient is an 83-year-old male with coronary artery disease who presented to the hospital with dizziness and 
hypotension requiring vasopressors. Initial assessment revealed the following lab values: potassium 5.6, Cr 
2.93 later rising to 4.43, and Hgb 7.3. Urinalysis did not reveal signs of acute tubular necrosis such as non-
hyaline casts to suggest such. Although acute kidney failure with tubular necrosis was not evidenced by the 
documented workup, acute kidney injury was certainly shown and a more appropriate diagnosis for this 
admission would be acute kidney failure, unspecified.  
 
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 inpatient hospital services provided on May 29, 2021, to June 13, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
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 RFA 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 enrollee has chronic low back pain. 
He underwent diagnostic medial branch blocks and obtained 100 percent pain relief; however, a second set of 
diagnostic blocks has not been completed. The criteria for coverage are not met and the RFA is 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 radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service August 11, 
2021. 
 
You asked the Plan to pay for procedure code 87634. The Plan denied your request. The Plan says payment for 
code 87634 is bundled into payment for code 87631.  
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 87634 
is a column II code to column I code 87631. 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 87634 billed for date of service August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from August 22, 2021, to 
August 31, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
secondary diagnosis code is supported. The Plan denied your request. The Plan says the provided 
documentation does not support the secondary diagnosis code that was billed. 
 
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 secondary diagnosis code, U07.1, defined as 
COVID-19. 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 at the 
DRG originally billed. Our reviewer says that the DRG originally billed was correct. Our physician reviewer 
found the provided documentation indicates that the enrollee tested positive for COVID-19 two weeks before 
they were admitted to the hospital. The reviewer found that patients with chronic lung disease are at an 
increased risk of severe respiratory illness owing to alterations in the local/systemic immune response, host 
microbiome, excessive mucous production, and poor pulmonary reserve. Therefore, the reviewer found that the 
DRG originally billed correctly.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided from August 22, 2021, to August 31, 2021, at the Diagnosis Related Group (DRG) 
originally billed.  
 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to the deductible for an outpatient clinic visit on January 25, 2022.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial stating an outpatient clinic is a specialist service. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $200 deductible, and this deductible applies to outpatient clinic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $200. This cost sharing is a contractual obligation that had not been met at the time of service. Therefore, we decided that the Plan does not have to waive the cost share applied to the deductible for an outpatient clinic visit on January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a T11 surgery. 
 
You asked the Plan to pre-approve a T11 surgery. You say that this has been an ongoing issue and has been 
causing the enrollee extreme pain. You say that the enrollee has been hospitalized due to the pain. You say that 
the enrollee was unable to speak during that time due to the extreme pain. The Plan denied your request. The 
Plan says the requested surgery is only covered if the backbone broke in the past 12 weeks. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation (PVA) is only 
covered for certain clinical indications.  
 
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 T11 surgery. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has multiple 
compression fractures on imaging. There is no documentation that the T11 fracture is less than 12-weeks old. 
 
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 T11 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a T11 surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 surgical management of infected tissue at a previous surgical site and was discharged home 
on November 3, 2022. 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, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but still somewhat unstable and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 7-month rental of a standard wheelchair 
(K0001). 
 
You asked the Plan to pre-approve an additional rental of a standard wheelchair. You say that you need the 
requested wheelchair due to chronic obstructive pulmonary disease. The Plan denied your request. The Plan 
says the request for a 7-month rental of a standard wheelchair was denied because the documentation supplied 
shows you are now with limited ability to ambulate but improving. The approved three (3) months will allow 
you time to regain strength and the ability to perform mobility related activities of daily living in the home. 
 
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 additional rental of a standard 
wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the medical records provided there is 
documentation that you have a personal mobility deficit, but detail is lacking in the provided records that the 
mobility deficit impairs participation in mobility related activities of daily living such as toileting, feeding, 
grooming, and bathing in customary locations within the home. Provided records do not clarify that the 
wheelchair meets Medicare criteria for the additional 7 months of use given that the most recent medical 
records provided indicate you are ambulating with a walker with no reported issues or falls. 
 
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 additional rental of a standard wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional 7-month rental of a standard wheelchair 
(K0001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service February 10, 
2022. 
 You asked the Plan to pay for procedure code 88321. You say that the medical records support the services 
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service February 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for noncontact real-time fluorescence wound imaging, for bacterial 
presence, location, and load, per session; first anatomic site (eg, lower extremity) provided to the enrollee on 
March 2, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that in the absence of clinical information, medical necessity and coverage cannot be 
determined. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had a non-healing left foot wound which was debrided on 3/6/22, followed by molecular 
light therapy. The procedure including the molecular light therapy was thoroughly documented in the operative 
note of 3/2/22 and should be approved. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; first 
anatomic site (eg, lower extremity) provided to the enrollee on March 2, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis services provided from June 2, 
2022, through June 9, 2022. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you should not be 
responsible for this bill. 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 20% 
coinsurance for Medicare-covered renal dialysis.  
 
You have been asked to pay a 20% coinsurance for the dialysis services. This item/service falls within the 
Medicare-covered renal dialysis 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 coinsurance for 
the dialysis services provided from June 2, 2022, through June 9, 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 the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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 is status post Non-ST-elevation myocardial infarction (NSTEMI). From 
a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs 
were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. 
The enrollee was at a modified independent to contact guard assist level with functional mobility including gait 
to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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.