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

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary. Our physician reviewer found the 
complexity of your nursing medical and rehabilitation needs does require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. You have suffered an acute neurological condition and 
would benefit from the intensity of rehabilitation physician oversight provided in the acute inpatient 
rehabilitation setting to monitor your neurological condition and medical issues. Your medical and 
rehabilitation needs do 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 documentation shows that the enrollee has active comorbidities however there are no 
complex functional impairments specified that would require intense therapy or an interdisciplinary approach 
to rehabilitation care in an IRF setting. Clinical documentation by evaluating therapists also document poor 
therapy tolerance due to variable heart rate thus there is no documentation to support that the enrollee would 
tolerate 15 hours of therapy per week. 
 
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: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for wound care services provided on November 5, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not support the services billed. Maximus partially overturned
the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
The Plan is correct in this case. In regard to codes 44005 and 97606, the Plan must follow Medicare rules.
Medicare rules say that providers must report services correctly. Providers must report services with the
appropriate codes. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural
Terminology (CPT) code 97606 - "Negative pressure wound therapy (eg, vacuum assisted drainage collection),
utilizing durable medical equipment (DME), including topical application(s), wound assessment, and
instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters."
The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 for an assistant at surgery. Our reviewer says that while the procedure
overall required an assistant surgery, CPT 97606 does not require the assistant. Our physician reviewer found
that application of a wound vac at the end of the surgery would not specifically require an assistant surgeon.
Additionally, in terms of CPT 44005, 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 code 44005 (Enterolysis (freeing of intestinal adhesion) (separate procedure)) is a column
II code to column I code 44144 with a modifier indicator of 0. The column II code is therefore not payable.
Based on the claim submitted, Medicare billing criteria have not been met.
Regarding code 37617, the records provided do not support the services billed. Our physician reviewer stated,
"The etiology of the bleeding cause is not able to be determined." In addition, the operative report did not
include documentation of a ligation of a major artery (post-traumatic, rupture) of the abdomen which is the
definition of code 37617; therefore, this code cannot be verified. 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 wound care services provided to the enrollee on November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus Gene Panel testing coded as 81479.
You asked the Plan to pay this claim. You say that this testing should be covered by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans decision
for insufficient claim information. The Plan requested a reopen and provided additional information. The Plan
demonstrated that code 81479 was submitted as a separate claim. The remaining codes were submitted on
multiple different claim forms, but all testing used the same specimen. The claim was billed with a date of
service inconsistent with Medicare rules governing laboratory services. Specimens were collected on
September 3, 2021, and September 21, 2021, rather than the billed date of service October 5, 2021.
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 dates of
service versus the dates billed have created a billing error based on Medicare guidelines Medicare rules for
coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for Tempus
Gene Panel testing billed with multiple codes, including 81479 for date of service October 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test (G0399). 
 
You asked the Plan to pre-approve a home sleep test. You say that this test is medically necessary and the 
enrollee's previous sleep study was from 2021. The Plan denied your request. The Plan says this test is not 
medically necessary as the enrollee has previously had a similar test which provided sufficient information to 
proceed with treatment. 
 
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 a home sleep test. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided documentation does not support the medical necessity of the 
requested sleep study, as the records document an adequate diagnostic sleep study was already performed on 
April 12, 2021. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home sleep test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home sleep test (G0399).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services received on May 10, 2022 and May 19, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that your policy states that you can get reimbursed 
for this type of doctor's visit. The Plan denied your request. The Plan says the services received are not a 
covered benefit. 
 
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 services received on May 10, 2022 and May 
19, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the requested procedure. The Plan denied your request. The Plan says the clinical value and effectiveness in 
the setting of chronic low back pain due to degenerative disc disease, vertobrogenic pain, and Modic type 
changes have not been demonstrated in the peer-reviewed literature. The Plan says that more research is needed 
to show safely and efficacy of the procedure. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, and more research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage 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 is correct in this case. 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. IRF
care is not considered medically reasonable and necessary based on Medicare guidelines. The medical records
do not reflect that at the time of the appeal, the enrollee required an intensive rehabilitation therapy program
consisting of at least three hours of therapy per day at least five days per week.
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), cone beam computed tomography (CT) capture and interpretation (D0367), apicoectomy (D3425), retrograde filling (D3430), and drugs or medicaments dispensed in the office for home use (D9630) provided on March 18, 2022.
You asked the Plan to pay for the dental services. You say that you had the abscess and issues that you were suffering from fixed. The Plan denied your request. The Plan says your benefit for the oral exam 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 Plan's 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 problem focused limited oral evaluation was exhausted on date of service February 15, 2022. Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam computed tomography capture and interpretation, apicoectomy, retrograde filling, and drugs or medicaments dispensed in the office for home use are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), cone beam computed tomography (CT) capture and interpretation (D0367), apicoectomy (D3425), retrograde filling (D3430), and drugs or medicaments dispensed in the office for home use (D9630) provided on March 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the refund request for the outpatient rehabilitation services provided to the enrollee on February 1, 2021.
You asked the Plan to waive the refund request for the outpatient rehabilitation services. You say that the enrollee's plan says they paid the claim twice. You also say that the accounting department verified that this amount was not received for the enrollee. The Plan denied your request. The Plan says that overpayment was made initially. The Plan also says that the overpayment amount should be paid from the provider.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed.
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on September 29, 2021. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the outpatient rehabilitation services have not been met. Therefore, we decided that the Plan does not have to waive the refund request for the outpatient rehabilitation services provided to the enrollee on February 1, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a custom silicone prosthesis complete hand
(left fingers).
You asked the Plan to provide coverage for a hand prosthesis. You say that at the time of the appeal your
current prosthesis could not be replaced, and you needed a new one. The Plan denied your request. The Plan
says the requested prosthesis exceeded your needs and was not covered by Medicare. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan
noted that a Medicare approved prosthesis that meets your needs would have been provided if requested.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that for equipment to be
covered, it must primarily serve a medical purpose. The issue is not the need for a prosthesis but the fact that
the current prosthesis needed replacement. The prosthesis requested, based on the medical records and the
notes from the prosthetist, exceeds your medical needs and therefore would not be covered by Medicare.
Therefore, we decided that the Plan does not have to provide coverage for a custom silicone prosthesis
complete hand (left fingers) for your left hand.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that additional acupuncture treatments are medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of additional 
acupuncture treatments. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. The Plan offers an acupuncture benefit that exceeds Medicare coverage.   
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that the treatments appear to 
be for maintenance therapy and the request exceeds utilization criteria. The request for additional treatments is 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 8 additional acupuncture treatments.
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 you need a higher level of care than a 
skilled nursing facility. 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 you do not require services at the LTACH that are not available at the acute care 
hospital where you 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 25, 2022. 
 
You asked the Plan to pay for the office visit. You say that this was the initial visit with this enrollee. The Plan 
denied your request. The Plan says the claim was not billed with a modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 We looked at the file and the rules. The claim information shows that a clinical trial number and a secondary 
diagnosis code of Z00.6 was billed, indicating services as part of a clinical trial. The claim does not show that a 
modifier was appended to the procedure code as required. Based on this information, we decided that Medicare 
rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit provided on May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
left total knee arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The 
Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 
2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a left total knee arthroplasty. The record does 
not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.