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

 
We decided that the Plan does not have to pay for an Arrhythmia and Cardiomyopathy Comprehensive Panel 
provided to the enrollee on August 9, 2022. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for an Arrhythmia and 
Cardiomyopathy Comprehensive Panel provided to the enrollee on August 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH 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. 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. 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 health plan. The 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64640 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the procedures were billed as per guidelines. 
The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 64640 is destruction by neurolytic agent; other peripheral 
nerve or branch. 
 
We find that CPT code 64640 is not supported in the medical record. The records show that the enrollee 
received sacroiliac joint radiofrequency ablation services. There is a more appropriate code available that 
describes the services provided. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 64640 billed for date of service April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not 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 the home ventilator. Our physician 
reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive 
pulmonary disease. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel 
positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability. 
The Plan has indicated coverage for such a device is available upon request. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) services. 
 
You asked the Plan to pre-approve TTE services. You say that the records provided support the need for the 
services in dispute. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve TTE services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted medical records do not show the enrollee has any cardiac symptoms. Clinical 
guidelines do not support carrying out a TTE in this setting and there is no supportive evidence for the medical 
necessity of a TTE in this patient's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 29, 2022, to 
September 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 29, 2022, to 
September 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 25, 2022, to 
February 27, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and appropriate. The Plan denied your request. The Plan says that it was not medically necessary to 
treat the enrollee at the inpatient level at this time; the necessary care could be safely provided in an outpatient 
observation level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission, the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 25, 2022, to February 27, 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 central mount power elevating leg rest/platform, 
specialty joystick, extension transfer-assist tie-downs for transport, and power seat elevator. 
 
You asked the Plan to pre-approve central mount power elevating leg rest/platform, specialty joystick, 
extension transfer-assist tie-downs for transport, and power seat elevator. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are only covered for 
certain 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 central mount power elevating leg 
rest/platform, specialty joystick, extension transfer-assist tie-downs for transport, and power seat elevator. Our 
reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found the enrollee has cerebral palsy and functional quadriplegia but can 
stand pivot transfer independently. The enrollees strength in the upper extremities is three out of five. The 
enrollee has adequate strength in upper extremities to manage standard switches. There is no justification 
provided for specialized joystick. The enrollee does not have flexion contractures of her knees requiring power 
leg rests. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. The requested power seat elevator is 
specifically not covered. The requested extension transfer-assist tie-downs for transport is non-covered as it is 
for outside the home. The enrollee does not meet criteria for the requested central mount power elevating leg 
rest/platform and specialty joystick. Based on this information, we decided that Medicare rules for coverage of 
central mount power elevating leg rest/platform, specialty joystick, extension transfer-assist tie-downs for 
transport, and power seat elevator have not been met. Therefore, we decided that the Plan does not have to pre-
approve central mount power elevating leg rest/platform, specialty joystick, extension transfer-assist tie-downs 
for transport, and power seat elevator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 31, 2021, to 
August 2, 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 it is felt 
that the appropriate DRG was billed for this stay. The Plan denied your request. The Plan says the principal 
diagnosis was not supported which reduced the DRG payment. 
 
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 principal diagnosis code J96.01, defined as acute 
respiratory failure with hypoxia. 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 reported principal diagnosis code is 
not supported by the records for this hospital stay. Our physician reviewer found the enrollee required a 
maximum 4 liters of oxygen in the emergency department, which was reduced to 2 liters. By the next day, he 
was saturating 95% on room air. He was not described as having increased work of breathing. Arterial blood 
gas studies were not done. The pulmonologist did not diagnose respiratory failure but did diagnose hypoxemia. 
The fact that others used the term respiratory failure in the record does not override the fact that his degree of 
respiratory compromise was able to be overcome with 4 and then 2 liters of supplemental oxygen. This does 
not constitute a life-threatening derangement. The review has determined that the documentation did not 
support principal diagnosis code J9601.  
 
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 July 31, 2021, to August 2, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81225, 81226) provided on September 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported as 
billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81225, 81226) provided on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an infusion set for external insulin pump, non-needle 
cannula type (A4230) and a syringe with needle for external insulin pump (A4232). 
 
You asked the Plan to pre-approve an infusion set for external insulin pump and a syringe with needle. You say 
that your current insulin pump is no longer in warranty, has an odor and is possibly leaking. You also say the 
pump has been recalled several times, and you are almost completely out of supplies for current pump. The 
Plan denied your request. The Plan says the infusion set is not valid because it is included under code A4224 
which was approved. The Plan also says the syringe with needle is invalid for submission to Medicare and 
should not be used for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file and Medicare rules. The LCA confirms code A4230 is not valid for claim submission to the DME MAC because they are included in code A4224. The LCA also confirms code A4232 does not 
include the drug for use in the reservoir and is invalid for submission to Medicare and should not be used for 
this purpose. Based on this information, we decided that Medicare rules for coverage of an infusion set for 
external insulin pump and a syringe with needle have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an infusion set for external insulin pump, non-needle cannula type (A4230) and a 
syringe with needle for external insulin pump (A4232).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81479) provided to the enrollee on March 12, 2022.
You asked the Plan to pay for the laboratory services. You say that these services were necessary and are supported in the medical record. The Plan denied your request. The Plan says that the specimen was collected during a hospital outpatient encounter.
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 collected in the hospital. 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 (81479) provided to the enrollee on March 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test, provided on May 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that the reported results for the testing ordered 
for the enrollee is time sensitive and needed by the ordering physician timely so that the physician can make an 
informed decision on the enrollee's course of treatment. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test, provided 
on May 25, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 6, 2022, to 
February 7, 2022, 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 
diagnosis of G93.41 metabolic encephalopathy is supported in the medical record, so the DRG should have 
been paid as billed. The Plan denied your request. The Plan says the billed diagnosis of G93.41 (metabolic 
encephalopathy) is not supported in the medical record, resulting in a lower DRG being paid. 
 
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 diagnosis code G93.41 (metabolic encephalopathy). 
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 billed diagnosis of G93.41 (metabolic encephalopathy) is not 
supported in the medical record. Our physician reviewer found the member is an 83-year-old male with a past 
medical history including dementia, previous stroke, cardiac disease, hypertension and diabetes mellitus who 
was admitted to the hospital with fever and increased confusion. He was diagnosed and treated for a urinary 
tract infection with fever. The documentation doesn't clearly define his baseline cognitive impairment and if the 
member was impaired cognitively beyond his baseline. The documentation does not indicate that the diagnostic 
work-up and treatment ordered by the treating medical providers supported a diagnosis code G93.41 (metabolic 
encephalopathy).  
 
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 February 6, 2022, to February 7, 2022, at the Diagnosis Related 
Group (DRG) originally billed.