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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 23, 2021 to 
November 1, 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 this 
should be paid for. The Plan denied your request. The Plan says the determination to remove diagnosis code 
A41.89 (Other specified sepsis) and R65.20 (Severe sepsis without septic shock) remains upheld. 
 
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 DRG 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the hospital appears to have coed for sepsis based on presence of SIRS criteria. No SOFA criteria were 
present - no renal, hematological, cognitive, biliary, respiratory, or hemodynamic criteria for sepsis were 
present.  
 
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 October 23, 2021 to November 1, 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 provided on May 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that this lab testing is covered by Medicare, so this 
claim should be paid. 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 provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket system for a prosthetic leg. 
 
You asked the Plan to pre-approve the requested vacuum socket system. You say that this item would be very 
beneficial to the enrollee. The Plan denied your request. The Plan says this is not proven to be a medically 
necessary item. 
 
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 requested vacuum socket system. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the vacuum pump residual limb management and moisture evacuation system 
exceeds the enrollee's medical needs and is not proven superior to a standard socket. Therefore, it does not 
meet Medicare medically necessary criteria. Per documentation, the physician note indicates a recommendation for an elevated vacuum system. The literature reviewed indicates that further research is needed with clinical 
trials that recruit larger sample sizes and report long-term outcome data for the requested vacuum suspension 
system. 
 
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 requested vacuum socket system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vacuum socket system for a prosthetic leg.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from September 9, 2022, to September 11, 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 documents do not support this level of care. 
 
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 99223 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high 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 
unstable or has developed a significant complication or a significant new problem. Typically, 35 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 the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented to the 
emergency room with low back pain, ongoing for two weeks. The enrollee is wheelchair bound due to prior 
stroke. The enrollee takes Lyrica. Physical examination documentation was not detailed and was essentially 
unremarkable. Analgesics were adjusted. However, the provided records did not clearly show a detailed 
interval history or a medical decision making of high complexity to support the 99233 code.  
 
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 subsequent hospital care (procedure code 99233) rendered from September 9, 2022, to 
September 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological/neuropsychological testing (96136, 
96137 x 11, 96130, 96131 x 5, 96132 and 96133 x 5). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says psychological/ neuropsychological testing is not medically necessary 
 
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 services. Our physician reviewer 
found the documentation showed the enrollee did not meet necessity criteria as the enrollee has a lack of 
medical or neurologic disorder which would cause the enrollee's cognitive impairment. This enrollees 
condition can be diagnosed in a clinical interview with clinical history and Diagnostic and Statistical Manual of 
Mental Disorders (DSM)-5 criteria. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve psychological/neuropsychological testing (96136, 96137 x 11, 96130, 96131 x 5, 96132 
and 96133 x 5).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided on November 18, 2021, to
November 26, 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 these
services were supported. The Plan denied your request. The Plan says that that the billed DRG is not supported.
Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with principal
diagnosis code, A41.51, defined as Sepsis due to Escherichia coli (E. coli). Our Medical Director states that a
constellation of clinical, laboratory, radiologic, physiologic, and microbiologic data is typically required for the
diagnosis of sepsis. The available documentation supports the billing of DRG 871 (Septicemia or severe sepsis
without mechanical ventilation greater than 96 hours with major complication or comorbidity). Our Medical
Director found that the enrollee's condition met Medicare criteria for the inpatient hospital services provided
from November 18, 2021, to November 26, 2021, at the DRG originally billed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient
hospital services provided on November 18, 2021, to November 26, 2021, at the Diagnosis Related Group
(DRG) originally billed.
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 77002 billed for date of service March 4, 
2022.  
You asked the Plan to pay for procedure code(s) 77002. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 77002. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 77002. Based on this information, 
we decided that Medicare rules for coverage of procedure code 77002 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 77002 billed for date of service March 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (92134, 92235, 92250, 99214) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (92134, 92235, 92250, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97150 billed for date of service November 3, 
2022. 
 
You asked the Plan to pay for procedure code 97150. You say that this claim should be paid as in-network. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. You have 
not provided any medical records to support this claim despite multiple requests. The Plan has paid for 1 unit in 
accordance with the allowed MUE amount. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 97150 is 1. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 97150 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 97150 billed for date of service November 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment program (OTP) services provided on November 7, 
2022. 
 
You asked the Plan to pay for the OTP services. You say that the program is certified and should be paid for 
these services. The Plan denied your request. The Plan says that this was billed by a physician which is not 
allowed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has incorrect indicated that the services at issue were billed by a 
physician, rather than an OTP provider. However, the OTP provider is the billing provider on the claim, which 
was submitted as a professional claim which is specifically allowed based on the rules. We find that there is no 
alternate rationale given in support of this denial of payment. As such, it is not substantiated. Therefore, we 
decided that the Plan has to pay for the opioid treatment program (OTP) services provided on November 7, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Graftjacket Xpress. 
 
You asked the Plan to pre-approve Graftjacket Xpress. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Graftjacket Xpress. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found your ulceration does appear to be healing with standard wound care, Prisma, Santyl, 
and foam dressings. If at any point the ulceration stalls, in that the measurements do not demonstrate 
improvement, Grafix can then be considered reasonable. Until that point, it does not appear that the requested Grafix/Graftjacket Xpress is medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Graftjacket Xpress have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Graftjacket Xpress.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service April 6, 
2022. 
 You asked the Plan to pay for procedure code 87634. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632. 
 
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 87634 
is a column II code to column I code 87632. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87634 billed for date of service April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on September 7, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and appliance provided on September 7, 2022.
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. You say that you cannot return home because you have not been 
able to get out of bed. You also say that therapy will improve your health so you can return home. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for a SNF admission. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services billed to the enrollee from July 4, 2021,
to August 2, 2021.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan notes that
Per Medicare Claims Processing Manual Chapter 10, Section 10.1.15, Payment Adjustments - Partial
Period Payment Adjustment: both transfer situations and discharge and readmission to the same agency in a 30-
day period result in shortened periods of care. In such cases, payment will be pro-rated.
Partial period payment adjustments occur because of the two following situations: a. When a patient has been discharged and readmitted to home care within the same 30-day period of care, or b. When a patient transfers to
another HHA during a 30-day period of care. Both situations are indicated on the claim by reporting a Patient
Discharge Status code of 06. Based on the presence of this code, ricer calculates a partial period payment
adjustment to the claim. Please note, it's not actually the date of service span that is inappropriate, it is the
patient discharge status code 06 in relation to that date span that is the issue. The 06-discharge status code should only be used to indicate a shortened period claim due to scenario A or B in Medicare Claims Processing
Manual Chapter 10, Section 10.1.15. As the provider billed for the full 30-day period with no discharge,
scenario A does not apply. Scenario B would not apply either as the member did not transfer to a different
HHA as evidenced by subsequent HH claim 028744522 submitted by the same provider for date span August
3, 2021, to August 11, 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, this claim shows billed errors due to the reported patient discharge status of code 06 in relation to that date span that was reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services billed to the enrollee from July 4, 2021, to August 2, 2021.