Persius/hicric huggingface dataset:
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 the enrollee will require continued 
complex respiratory medical care, daily multi-specialty physician follow up, daily laboratory testing, and 
physical therapy and/or occupation therapy for at least 28 more days. You also say skilled nursing facilities do 
not have the necessary equipment to provide this level of support. The Plan denied your request. The Plan says 
the requested LTACH services not medically necessary. 
 
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 all medically necessary care is being provided in the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (64483x6, 
64884x6). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that these injections are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet approval for these 
injections. 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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back pain. She has received transforaminal 
epidural steroid injections but the request for repeat injection is requested before 3 months have passed. There 
is no imaging report submitted for review. Repeat ESI can only be done if prior ESI has at least 50% sustained 
improvement in pain or 50% improved function measured from baseline for at least 3 months. There is a lack 
of documentation. Therefore, at this point, the request is deemed not medically reasonable and 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transforaminal epidural steroid injections (64483x6, 64884x6).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1686, L2624) provided on November 23, 2022. 
 
You asked the Plan to pay for the orthotics. You say that medical records were submitted for review. The Plan 
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply 
code. 
 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 orthotics. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the patients medical record does not contain sufficient documentation of the patients medical condition 
to substantiate the necessity for the type and quantity of items ordered. The enrollee has been doing exercise at 
home, and was ambulating normally on physical examination. There are no transportation difficulties. 
 
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 orthotics have not been met. Therefore, we decided that the Plan does not 
have to pay for orthotics (L1686, L2624) provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 4, 2022, under claim Claims A.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan noted that this claim denied because the Plan previously paid for these services under another claim. These services were paid to the same provider group for the same date of service. The Plan included the claim image for the appealed and referring claims.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems.
Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 4, 2022, under claim Claims A.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport billed to the enrollee for April 20, 2022.
You asked the Plan to pay for this claim. You say that this transport should be paid for 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 this claim denied because the service was billed with an inappropriate modifier. This service was billed with a Modifier of "RW" which is not an appropriate destination modifier for use with ET3 ambulance claims. The Medicare Claims Processing Manual - Chapter 15 - Ambulance - Section 30 - General Billing Guidelines - A) Modifiers specific to Ambulance Service Claims explains how ambulance services should be billed and what modifiers should be used. The case file includes the appealed claim that shows the provider has billed inappropriately. The Plan notes modifier "W" is an inappropriate destination modifier for use with ET3 ambulance claims because it does not apply to plans. This only applies to Private-Fee-For-Service (PFFS) Plans.
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 and when necessary the appropriate modifiers.
In this case, this claim could not be paid as billed due to the submission of an inappropriate modifier. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport billed to the enrollee for April 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport provided on February 19, 2022.
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that the medical records provided support the need for the ambulance transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.
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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found there was no documentation provided indicating medical necessity for ambulance transport. The enrollee was stable and appropriate for transportation by other means than ambulance and required no monitoring. 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport provided on February 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each (26080) provided to the enrollee on August 5, 2022.
You asked the Plan to pay for these services. You say that this should be paid for. The Plan denied your request. The Plan says that the records do not support the services billed.
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 26080 is "Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each."
Our Medical director looked at the case file and the reopen request. At issue is payment for the arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each (26080). Our Medical Director states that the documentation in the Operative Note dated 08/05/22 does not document CPT 26080: Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, for the index finger. Rather, the documentation supports that metacarpophalangeal joint of the index finger was operated on. Our reviewer found that these services were not supported in the records. We looked at this physician 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 pay for the arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each (26080) provided to the enrollee on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
12, 2022. 
 You asked the Plan to pay for procedure code 86077. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service February 9, 
2022. 
 
You asked the Plan to pay for procedure code 94761. The Plan denied your request. The Plan says procedure 
code 94761 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. In this case, there 
were other services billed on the same date by the same provider. This means that procedure code 94761 is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 
94761 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 94761 
billed for date of service February 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on September 13, 2022. 
 You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid The Plan denied your request. The Plan says these codes were bundled into payment for code 
37244. 
 
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 75625-26-XU and 75726-26-XU are column II codes to column I 
code 37244; however, 75625-26-XU and 75726-26-XU was billed with a modifier.  
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the medical records provided do not 
include sufficient documentation to validate the use of Modifier XU is appropriate, therefore this service 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of imaging services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on September 13, 2022.
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 the enrollee's acute needs have been met 
and stabilized in the acute setting and they are stable to transfer to the LTACH for the continuation of care. The 
Plan denied your request. The Plan says the requested LTACH services are not medically necessary. 
 
 
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 all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on November 14, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that the service should be covered. The 
Plan denied your request. The Plan says the member was enrolled in Hospice at the time of service. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency room services provided on November 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine(90750), provided on November 16, 
2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine(90750), provided on 
November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA Molecular Signature test (81479) provided August 
18, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please find the appeal information that 
describes the medical necessity of the PrismRA test to inform consideration of payment. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the PrismRA Molecular Signature test in the 
setting of inflammatory arthritis have not been demonstrated in the peer-reviewed literature.  
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee is diagnosed with inflammatory arthritis. The 
Health Plan must follow CMS rules and guidance per LCD L38294. Noncovered Indications PGx testing is not 
covered when a treating clinician is not considering treatment with a medication that has an actionable drug-
gene interaction, or when the use of a medication with a drug-gene interaction is not reasonable and necessary. 
The clinical value and effectiveness of the PrismRA Molecular Signature test in the setting of inflammatory 
arthritis have not been demonstrated in the peer-reviewed literature. The review has determined that the 
items/services at issue in this case are 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for PrismRA Molecular Signature test (81479) provided August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical simulator supplies (A4595), provided on 
November 2, 2022. 
 
You asked the Plan to pay for the electrical simulator supplies. You say that the item should be covered. The 
Plan denied your request. The Plan says there is not a valid physician order. 
 
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 for the supplies provided in this case. The order was not 
signed and dated. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the electrical simulator supplies 
(A4595), provided on November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health visits for physical therapy. 
 You asked the Plan to pre-approve additional home health visits. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found that 
clinical documentation does not show that the enrollee is homebound. A home exercise plan has been enforced; 
thus, the skilled assessment/treatment by a physical therapist would not be further required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 9 additional home health visits for physical therapy.