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

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 30, 2022, to 
June 4, 2022. 
 
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 Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 177. 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 cause of the pneumonia is not known. There is no laboratory data supporting gram negative 
pneumonia. It is common the exact cause is not known and so broad coverage as in this case is used. Coding 
for gram negative pneumonia is not supported in the record. The enrollee did present with metabolic 
encephalopathy likely secondary to his primary condition of pneumonia and co-morbidities. The condition did 
not complicate his stay, require additional diagnostic work or prolong length of stay. DRG 194 - simple 
pneumonia with complications - is consistent with the enrollee's medical course.  
 
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 rendered from May 30, 2022, to June 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 3, 2022.
You asked the Plan to pay for these services until they are addressed by primary insurer at that time. You say that you are hopeful your secondary insurer will still accept the claim and make some payment pending a determination of responsibility by your primary insurance company. You filed this appeal to present this in a timely manner and preserve your appeal rights.
The Plan denied your request. The Plan says an Explanation of Benefits showing these services were addressed by the primary provider have not been received. Maximus overturned the Plans denial. The Plan requested a reopen and provided confirmation that you had another primary carrier at the time of service and attempts have been made by the Plan to resolve this issue.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. The Plan and your appeal confirm that you had a primary insurer at the time of service. The Plan has shown their attempts to contact the primary insurer to resolve this issue. The Plan has met its obligation with regards to coordination of benefits. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on June 3, 2022.
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 the enrollee meets all applicable Medicare criteria for admission to an IRF. The Plan denied your request. The Plan says that the Medicare guidelines for IRF admission were not met and the enrollee can receive the care they need in a lower-level setting.
Our Medical director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and accessories (E0953, E0955, 
E0961, E0971, E0973, E0990, E1028, E1161, E2204, E2231, E2609, E2617, K0040, K0108). 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that the requested custom 
wheelchair is needed for the enrollee because the wheelchairs at the current facility are not meeting his needs. 
The enrollee cannot perform an effective weight shift due to weakness. The requested wheelchair will tilt to 
give him the pressure relief needed, sitting tolerance he desires to take part in the facility and family activities, 
as well as proper righting actions for improved posture. The Plan denied your request. The Plan says the 
enrollee lives in a long-term care facility (LTCF). Medicare only covers DME for use in the home. The request 
was denied as a LTCF is not considered home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair and accessories is being requested for use in a LTCF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories (E0953, 
E0955, E0961, E0971, E0973, E0990, E1028, E1161, E2204, E2231, E2609, E2617, K0040, K0108).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment (L0180) provided on November 8, 
2022. 
 
You asked the Plan to pay for the equipment. The Plan denied your request. The Plan says that the 
documentation submitted did not sufficiently support the billed supply code. 
 
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 argues that the documentation submitted did not sufficiently support 
the billed supply code. However, the records contain an itemized shipment receipt dated November 8, 2022, 
with the same tracking number as the delivery ticket dated November 18, 2022. As such, the records support 
that the items at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the durable 
medical equipment (L0180) provided on November 8, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on November 12, 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 enrollee did not have prior authorization for out of network care. Maximus overturned the Plans denial because the case file lacked the correct Plan contract. The Plan requested a reopen and provided the correct contract for review.
The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network lab services provided to the enrollee on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on November 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was under 
observation when the services were provided. 
 
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 99223 is not supported in the medical record. Specifically, the records 
show that the enrollee was under observation status when the services were provided. As such, it is 
inappropriate to bill an inpatient evaluation and management code and inpatient POS code (21) for the services 
in question. 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 (99223) provided on 
November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a swallowing function x-ray (code 74230), upper gastrointestinal tract x-ray (code 74240) and speech-language pathologist's participation in the MBS or video fluoroscopy (92611) provided to the enrollee on September 9, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan while a portion of this claim was paid, the denied codes are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules state that certain procedures and examinations are not covered under the portable x-ray provision. Based on these guidelines, codes 74230, 74240 and 92611 are not covered services in this setting. Therefore, we decided that the Plan does not have to pay for a swallowing function x-ray (code 74230), upper gastrointestinal tract x-ray (code 74240) and speech-language pathologist's participation in the MBS or video fluoroscopy (92611) provided to the enrollee on September 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is necessary because your goal is 
to return home within 7 to 10 days, and you are fearful that will not happen if you go to a nursing home. The 
Plan denied your request. The Plan says the requested IRF admission is not supported based on the records 
received. 
 
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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for a fall, weakness, hyponatremia, and anemia. Your medical problems are stable and there are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may have 
a need for physical therapy and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 an IRF admission and services.
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 the enrollee's best chance for a quicker 
recovery and more favorable outcome will be with admission to the LTACH. The Plan denied your request. 
The Plan says the requested LTACH admission 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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services billed to the enrollee a second time under code 99291-25 for date of service February 14, 2022.

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 for insufficient claim in formation. The Plan requested a reopen and provided the additional claim showing this service was billed twice, exceeding the allowed MUE unit for the same enrollee on the same day for code 99291.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. The records provided show code 99291 was billed to the enrollee on two separate claims, which is not allowed according to the Medicare billing criteria. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee a second time under code 99291-25 for date of service February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for code 71250-26 billed for date of service July 21, 2022.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. The Plan says code 75574 has a column I, column II code relationship with code 71250 and was billed and paid for the same date of service. 
Maximus overturned the Plans denial for insufficient claim information in the case file to show code 75574 had either been billed or paid. The Plan requested a reopen and provided the required information.

The Plan is correct in this case The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, The Plan has shown documentation that code 75574 was previously billed and paid for this date of service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 71250-26 billed for date of service July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that home BiPAP is not clinically sufficient for 
chronic respiratory failure. BiPap with AVAPS is not able to be used due to its low-pressure limit and minimal 
flow capacity. A device with backup battery for mobility and alarms for safety are necessary for this enrollee. 
The Plan denied your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS 
mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in targeted tidal volume, volume assured pressure support 
(TTV-VAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with average volume 
assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): 
"Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD 
policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care supplies to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve wound care supplies 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 
wound care supplies to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81479) provided on August 23, 2022. 
 
You asked the Plan to pay for the testing. 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 81479 is "Unlisted molecular pathology procedure". 
 
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 testing. Our reviewer says that the use of code 81479 is 
not supported by the records provided. Our reviewer found that the results show that a targeted hematology 
analysis panel was performed. There is a more specific code for this procedure, an unlisted code should not be 
reported.  
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing (81479) provided on August 23, 2022.