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

 
We decided that the Plan does not have to pay for deep implant removal (procedure code 20680) provided to 
the enrollee on February 1, 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 the denied code 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 20680 is "Removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate)." 
 
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 procedure description was 
noted and at the end, a note was made that there was metal hardware from previous surgery embedded in the 
bone (which had to be removed using graspers and screwdrivers.) As this was noted at the end of the procedure 
and not documented clearly as being other than minimal and essentially incidental, it cannot be determined to be a significant separate procedure. The notes as written appear that this was essentially performed during the 
reverse total arthroplasty. Therefore, the records do not support that CPT 20680 was a separate and distinct 
procedure from CPT 23472: arthroplasty, glenohumeral joint, total shoulder (glenoid and proximal humeral 
replacement (e.g., total shoulder)).  
 
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 deep implant removal (procedure code 20680) provided to the enrollee on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital admission provided from April 
23, 2022, to April 24, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says no 
acute care was rendered. The Plan also says that the enrollee could have been evaluated and treated in the 
emergency room and followed as an outpatient setting. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee presented to the emergency department with weakness, 
lightheadedness, and sleepiness since taking their home medications in the morning. The enrollee reported 
having recently started Atorvastatin 40 mg. Our reviewer found that the enrollee's Atorvastatin dose was 
lowered to 10 mg and symptoms improved. Our physician reviewer also found based on the low complexity 
and low severity of this presentation, and as the enrollee quickly improved with fluids and medication dose 
change, it was not expected that the enrollee would require hospital services that would likely cross 2 
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 the acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital admission provided from April 23, 2022, to April 
24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 30, 2022, 
to July 31, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee's clinical case was low complexity and low severity. 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on July 30, 2022, to July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on June 24, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the records were 
received and confirmed that the charges were billed with a medical diagnosis of age-related nuclear cataract, 
bilateral. An eye refraction is only covered by your Plan if performed by a participating vision provider and 
performed as a routine screening. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on June 24, 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 enrollee would benefit from continued skilled 
therapy services. You also say that you would like this denial to be reconsidered for the enrollee's safety. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve telomerase reverse transcriptase (TERT) gene analysis 
(81345). 
 
You asked the Plan to pre-approve the genetic testing. You say that please review attached clinical information 
for authorization. The Plan denied your request. The Plan says the documentation does not support the medical 
necessity for this test. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this test is typically used prior to cystoscopy to determine if the patient may have 
cancer. However, the provided records show that the enrollee has already had cystoscopy and was found to not 
have evidence of bladder cancer, making the TERT testing not medically necessary or reasonable in this case. 
There was no evidence in the provided documentation describing any reasoning that the testing would lead to 
clinical improvement. 
 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve telomerase reverse transcriptase (TERT) gene analysis (81345).
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 based on the enrollee's ongoing complex 
medical needs, you have determined that the enrollee is stable and suitable for transfer to LTACH. You also 
say that the enrollee requires daily physician management with close medical monitoring and cannot be 
adequately care for in her current condition at a skilled nursing facility as evidenced by multiple short-term 
acute care (STAC) readmissions from this level of care. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information they have about the enrollee's condition; the enrollee does not meet all 
the requirements. 
 
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 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. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1230). 
 
You asked the Plan to pre-approve a power scooter. You say that you have a hard time walking the long 
hallway in your building to access the laundry room and garbage. You have a hard time walking from point A 
to point B and the scooter will make your daily activities easier. The Plan denied your request. The Plan says 
coverage cannot be provided for the requested power scooter, the Medicare criteria has not been met, as the 
request does not address the elements of the coverage criteria of the requested service. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 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 scooter. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is no documentation that you have a 
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, 
feeding, grooming and bathing in customary locations within the home. There is no documentation that your 
mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. 
 
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 scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (E1230).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve MBBs. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 MBBs. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the enrollee's pain is related to 
thoracic vertebral compression fractures. The review has determined that the enrollee does not meet the 
coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medial branch blocks (MBBs).
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. 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 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 that you do not have documented skilled nursing or skilled therapy needs. Your care 
needs, custodial and intermittent, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services (99308) provided on June 16, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that payment for CPT code 99308 is not supported in the medical record. Specifically, the claim was 
billed with an office setting place of service (POS 11). However, code 99308 is for skilled nursing services, 
which means that a skilled nursing facility place of service should be billed. 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 the skilled nursing services (99308) provided on June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 87631 (Infectious agent detection by nucleic acid (DNA or RNA) provided to the enrollee on January 6, 2022.
You asked the Plan to pay for these services. You say that these services should be paid for by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan stated that states code 87631 was submitted for a Respiratory Pathogens & Antibiotic Resistance Panel. The submitted documentation indicates more than five (5) targets. The Plan states there is a more appropriate code to describe the services provided.
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, the Plan administratively denied the claim as the code submitted is not appropriate for the services described. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for procedure code 87631 (Infectious agent detection by nucleic acid (DNA or RNA) provided to the enrollee on January 6, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ziextenzo (Q5120) medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there is no documentation provided that indicates 
that the enrollee has tried or failed or has a contraindication to the Plan 's preferred drugs. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 this medication. Our reviewer says that 
the enrollee does not meet criteria for coverage of the requested medication. Our physician reviewer found that 
the documentation indicates that the enrollee's diagnosis is limited stage small cell lung cancer and Kaposi 
sarcoma. There is no documentation provided that indicates the enrollee has tried or failed the Fulphila, 
Neulasta, or Udenyca preferred drugs. The Plan requires a trial of these drugs before they will approve the 
requested drug. There is no documentation provided indicating that the plans required drug(s) would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Ziextenzo (Q5120) medication.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided from November 25, 2021, to 
December 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit". 
 
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  Our reviewer found that 
the medical records do not support the use of office visit code 99232 for the billed dates of service. 
 
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 the services (99232) provided from November 25, 2021, to December 9, 2021.
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 a skilled nursing facility is not the 
appropriate level of care at this time due to the complexity of the enrollee's care needs. The Plan denied your 
request. The Plan says the request is 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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.