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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 enrollee's clinical documentation shows that the enrollee has active medical 
comorbidities however no complex functional impairments have been specified thus the complexity of the 
enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. IRF criteria not met. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on November 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152-59 (1 Unit) remains 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 99152-59 is not supported as a separate and distinct procedure. According to Medicare guidance, G0500 is the correct code to 
report the first 15 minutes of sedation when performed by the same provider for gastrointestinal endoscopic 
procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested ventilator is not 
medically necessary. 
 
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 requested home ventilator is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee has severe chronic obstructive pulmonary disease (COPD). The 
documentation indicates that during the enrollee's hospitalization for an acute exacerbation several months ago, 
arterial blood gas (ABG) was consistent with chronic carbon dioxide (CO2) retention. The reviewer found 
there is no ABG done while stable to confirm chronic CO2 retention.  The reviewer found that the enrollee has 
reportedly been on noninvasive ventilation at night at home, with either bilevel positive airway pressure 
(BiPAP) or a ventilator. There is no documentation of usage. Therefore, the reviewer found that the requested 
ventilator is 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation with an endodontist. 
 
You asked the Plan to pre-approve the dental services. You say that you have an abscess causing sinus 
problems and your dentist recommended treatment by an endodontist. The Plan denied your request. The Plan 
says dental services from an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation with an endodontist.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services billed for January 6, 2022, to February 4, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. 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 provided additional documentation. The Plan noted this claim denied because a correct Notice of Admission (NOA) required to process claims had not been received by the Plan for the new 2022 series of Home Health (HH) billing as is required by Medicare. The Plan notes they received an NOA claim on May 26, 2022, that showed an admission date of January 6, 2022. However, the records show the claim was billed with an admit date of June 10, 2021, which is incorrect as it should have reflected the correct January 6, 2022, admit date.
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 NOA. In this case the NOA submitted, and the claim submitted do not have the same admission date. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services billed to the enrollee for January 6, 2022, to February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication of actual percentage of improvement and relief. 
 
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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation does not reveal any response to the injection done on 12/28/22. 
Therefore, there is no evidence that the enrollee has had 50% or more relief for 12 weeks from the last 
injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with Health Insurance 
Prospective Payment System (HIPPS) code 3EB11 provided May 26, 2021, to June 14, 2021. 
 
You asked the Plan to pay for the home health service as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed with a 
correct HIPPS code. 
 
We find that the home health services are not supported in the medical record as billed. Specifically, no visit 
notes or orders were provided for this episode of care. This means the HIPPS code billed is not supported. 
Based on this information, we decided that Medicare rules for coverage of the home health service as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services billed 
with Health Insurance Prospective Payment System (HIPPS) code 3EB11 provided May 26, 2021, to June 14, 
2021.
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 you are required to quarantine for 3 days following 
a cancer treatment due to the risk of radiation exposure to your grandchildren. You also say you need help with 
medication management, help with changing your insulin pumps and that you are a fall risk. The Plan denied 
your request. The Plan says admission to a SNF is not medically necessary. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on October 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no immediate significant threat to life. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical decision making was 
not of high complexity. The enrollee's condition/illness did not pose an immediate threat to life/limb. As such, 
the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft (20930). 
 
You asked the Plan to pre-approve allograft. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found osteopromotive allograft remains experimental is spinal surgery. Iliac crest autograft is the gold 
standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve allograft (20930).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
October 31, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. The rules say that only an entity enrolled with Medicare as an OTP can bill 
these codes. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on October 31, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313) and 
power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics and power seat elevation feature. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says the upgraded electronics 
are not medically necessary to control the power options through the joystick. The Plan also says that the power 
seat feature is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary for the enrollee to control the power options through the joystick. The rules also say that a power seat 
elevation feature is not covered because it is not primarily medical in nature. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee has adequate 
strength to manage the standard power drive switches. The request exceeds what is necessary to meet the 
enrollee's needs. 
 
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 upgraded electronics have not been met. The power seat elevation feature is 
not covered as it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-
approve the upgraded electronics (E2311, E2377, E2313) and power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99441) billed to the enrollee twice for
May 9, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case tile. The Plan requested a reopen and provided additional claim in
formation. The Plan demonstrated that the claim images and Provider Remittance Advice (PRA) for both
claims for date of service May 6, 2022, and the subsequent claim for date of service May 9, 2022, were
submitted for review. Each claim shows that they are from the same physician and billed with the same
diagnosis code of C44.309 or Unspecified malignant neoplasm of skin of other parts of face. Procedure code
99204 was billed on date of service May 6, 2022, which is 3 days prior to the May 9, 2022, date of service
under appeal. Procedure code 99441 for a Telephone evaluation and management service was billed for date of
service May 9, 2022. Both claims were billed by the same physician with the same diagnosis code. The records
show the two visits are clearly related. Code 99204 was billed on date of service May 6, 2022, which is within
the previous 7 days mentioned in the code description of 99441. Therefore 99204 was denied.
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, we claims submitted within 3 days of each other by the same provided for the same evaluation and
management code. Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for physician services (99441) billed to the enrollee twice for May 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for the enrollee.
You asked the Plan to pre-approve inpatient hospital care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
Our Medical director looked at the case file and the reopen request. At issue is coverage for inpatient hospital care. Our Medical Director states that no unstable medical conditions are identified.
The documentation does not support that it was medically reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for codes 87635, G2023, and 93005 provided on May 9, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim denied due to multiple errors. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and stated that code G2023 denied due
"OCE Edit 62", and has a status indicator of "B", which means code G2023 is a non-allowed item or service,
and not a code recognized by Medicare. Edit 62 has a Disposition of Claim Return to Provider (RTP), which
means there are one or more edits present that cause the whole claim to be returned to the provider. Due to this
RTP disposition, all other claim lines were denied and returned to the provider for corrections.
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 codes. In this case, this claim
contained errors that required the entire code to be returned for correction.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for to pay for codes 87635, G2023, and 93005 provided on May 9, 2022.