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

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88381 and 88360 billed for 
date of service February 10, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88381 and 88360. You say that these services 
were medically necessary and are supported in the medical record. The Plan denied your request. The Plan says 
these services were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88341, 88342, 88381 and 88360 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
inpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, 88381 and 88360 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88381 and 88360 billed for date of service February 10, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (49650) provided on November 3, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the code cannot be paid as 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. 
 
We find that CPT code 49650 is not supported in the medical record. Specifically, this code is a bilateral 
surgery code which must be billed with modifier 50 and a single unit of service. The code was inappropriately 
billed with the RT modifier. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (49650) provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller upgrade with harness and 
eight-way rocker for a power wheelchair. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an expandable controller is used to control 
multiple power options. 
 
We looked at the file and Medicare rules. The file shows that the expandable harness is not needed to control 
the approved power switches. The eight-way rocker is already included in the allowance for the expandable 
controller and harness upgrade. Given that the expandable controller and harness upgrade is not covered, the 
eight-way rocker is also not covered. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller upgrade with harness and eight-way rocker for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 is medically stable and does not need physician's supervision 3 times a 
week in an IRF. At the current level of function, the enrollee does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach in an IRF. While the 
enrollee may benefit from continued physical therapy, and occupational therapy, the enrollee's rehabilitation 
needs can be safely provided in a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that physical therapy and occupational therapists are 
recommending rehab, this would be the best type of care for the patient to regain their health and return home. 
The Plan denied your request. The Plan says admission to IRF was denied as not meeting AIR criteria, not 
medically necessary, and a lower level of care might be appropriate. SNF level of care was offered. 
 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you want an average volume assured pressure 
support (AVAPS) setting that a positive airway pressure (PAP) device cannot provide. The Plan denied your 
request. The Plan says Medicare does not cover a ventilator for the requested purpose and the enrollee's needs 
could be met by a bilevel positive airway pressure (BiPAP) device with AVAPS mode instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, are 
not covered.  
 
We looked at the file and Medicare rules. Medicare does not cover a ventilator for the requested purpose. The 
enrollees needs may be met by a positive airway pressure (PAP) device instead. Please contact the Plan for 
more information about the enrollees treatment options. Based on this information, we decided that Medicare 
rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve use of a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and a core buildup 
including pins when required (D2950) provided on December 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the services covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
The Plan provided documentation to show that the maximum annual allowance for your dental benefit had 
already been paid. 
 
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. 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted prior to the date of service. Therefore, we 
decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and a core buildup including 
pins when required (D2950) provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (e.g., hereditary 
hypercoagulability) gene analysis (81240) and F5 (coagulation factor V) (e.g., hereditary hypercoagulability) 
gene analysis (81241). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested testing is medically necessary. 
The Plan denied your request. The Plan says the F2 gene and F5 gene cannot be covered for the enrollee 
because her plan does not approve these blood tests. 
 The Plan must follow Medicare rules. Medicare rules say that the F2 gene and the F5 gene are not medically 
necessary. 
 
We looked at the file and Medicare rules. Medicare rules say the F2 and F5 genetic tests are not considered to 
be clinically efficacious and therefore, testing is not considered medically necessary. Based on this information, 
we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (e.g., hereditary 
hypercoagulability) gene analysis (81240) and F5 (coagulation factor V) (e.g., hereditary hypercoagulability) 
gene analysis (81241).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 The enrollee underwent right sided total knee arthroplasty for knee osteoarthritis on October 31, 2022 and was 
discharged home. She did not have any significant post-operative complications and her medical conditions are 
being managed on an outpatient basis. The enrollee does not require the intensity of rehabilitation physician 
oversight provided in the acute inpatient rehabilitation setting. Her medical and rehabilitation needs do not 
require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for services provided on 
January 7, 2022. 
 You asked the Plan to pay for the billed services. You say that the full billed rate is being requested. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. The records do not show that advanced 
care planning was performed. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99497 billed for services provided on January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has the medical and therapy needs 
required for an IRF admission. You say the enrollee would like seven days with the goal of going home with 
their daughter. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that the enrollee had a stroke. 
He had a heart monitor placed and it was not able to provide any information. You are hoping with the implant 
monitor it will provide the answers you need. The enrollee meets the requirements for the implant. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for an ILR and has a known history of 
atrial fibrillation s/p ablation with a CHADS2VASC score of 5. Implantation of an ILR to try to avoid 
anticoagulation is not medically necessary and is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found while the enrollee has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope or any other apparent indication for an 
ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in 
this enrollees 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 an implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown (D2954) 
provided on June 22, 2022. 
 
You asked the Plan to pay for prefabricated post and core in addition to crown (D2954). You say that you went 
to get a tooth pulled, but the dentist said they could crown it. You also say you do not understand why now you 
are getting a bill for the crown. The Plan denied your request. The Plan says there is no coverage for 
prefabricated post and core in addition to crown (D2954). 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
prefabricated post and core in addition to crown (D2954) provided on June 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. The Plan denied your request. The Plan says the documentation 
does not support that the enrollee has had prior directed therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enhertu. Our reviewer says that the 
requested use of Enhertu is not approved for the enrollees diagnosis. Our physician reviewer found that there 
was no prior HER2 based treatment. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are dissatisfied with the services rendered 
and question if the services were billed accurately. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 23, 2022. Therefore, 
we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
23, 2022.  
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle diabetic testing supplies. 
 
You asked the Plan to pre-approve Freestyle diabetic testing supplies. You say that you need these supplies. 
The Plan denied your request. The Plan says Freestyle supplies are not the Plan's preferred brand and your 
needs can be met by the preferred OneTouch brand supplies instead. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may limit coverage to certain durable 
medical equipment (DME) brands, items, and supplies. Your contract with the Plan says that the Plans 
preferred diabetic testing supply brand is OneTouch by Lifescan. 
 
We looked at the file and Medicare rules. The requested Freestyle supplies are not the Plans preferred brand. 
Your needs may be met by the Plans preferred brand products of OneTouch by Lifescan. Based on this 
information, we decided that Medicare rules for coverage of Freestyle diabetic testing supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Freestyle diabetic testing supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation per quadrant (D4921) for the upper left 
quadrant and the lower right quadrant provided from May 24, 2022, to May 25, 2022. 
 
You asked the Plan to pay for gingival irrigation per quadrant (D4921) for the upper left quadrant and the lower 
right quadrant. You say that before getting your treatment, you called the Plan representative, to confirm if this 
provider was in your network. You also say that you called the insurance specialist at the provider's office to 
confirm coverage, and both  the Plan representative and the insurance specialist confirmed your treatments 
would be covered. The Plan denied your request. The Plan says according to the 2022 EOC on pages 84 to 87, 
there is no coverage for gingival irrigation per quadrant (D4921).  
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation per quadrant (D4921) for the upper left quadrant and the lower right quadrant provided from May 24, 
2022, to May 25, 2022.