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

 
We decided that the Plan does not have to pay for more units of procedure code A0425 billed for date of 
service January 4, 2022. 
 
You asked the Plan to pay for more units of procedure code A0425. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value when the MAI value is 1 are only potentially allowable if the excess units are billed on 
a separate line item with an appropriate modifier.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 348 units of 
this code on a single line item, exceeding the MUE. You did not bill a separate line item for the 98 units in 
excess of the 250 MUE, nor did you bill these excess units with a modifier as required by Medicare billing 
rules. Based on this information, we decided that Medicare rules for coverage of more units of procedure code 
A0425 have not been met. Therefore, we decided that the Plan does not have to pay for more units of procedure 
code A0425 billed for date of service January 4, 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. The Plan denied your request. The Plan says the service requested 
is not supported based on the records we 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 the enrollee is medically stable. While the enrollee would benefit from physical 
and occupational therapy, the enrollee's rehabilitation needs can be safely provided in an alternate and low 
intensity setting such as in a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided from March 11, 2022, to 
June 9, 2022. 
 
You asked the Plan to pay for chiropractic treatment. The Plan denied your request. The Plan says the Plan 
allows up to 12 visits per calendar year for chiropractic services without authorization. The member met this 
limit prior to seeing this provider. There is no contact from the provider prior to services to check member 
insurance information, eligibility, or benefits. The provider did not obtain a prior authorization for services 
rendered beyond the allowed benefit limit (12 without authorization per calendar year). 
 
The Plan contract covers a routine chiropractic services benefit. The Plan says the Plan covers a maximum of 
12 visits per calendar year for routine chiropractic, acupuncture and naturopathic visits combined 
 
We looked at the file and the Plans rules. The file shows that the enrollee met the limit for routine chiropractic 
visits prior to these dates of service. Therefore, we decided that the Plan does not have to pay for chiropractic 
treatment provided from March 11, 2022, to June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix vaccine administered on May 23, 2022. 
 
You asked the Plan to pay for the Shingrix vaccine. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this vaccine is not covered under the 
enrollee's medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingrix 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine administered on 
May 23, 2022.  
 
Benefits for the Shingrix vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided to the enrollee on February
18, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the radiology services. You say that the referring provider ordered the test, and
you would like the claim reprocessed. The Plan denied your request. The Plan says that the rendering provider
is an OON provider and the service rendered was not urgent or emergent.
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 radiology services
provided to the enrollee on February 18, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 27, 2022, 
through April 1, 2022. 
 
You asked the Plan to pay for these services. You say that the inpatient hospital care provided was medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the services are not payable as they 
were rendered by an out-of-network provider, without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department with a finger swelling/redness and was 
diagnosis with an abscess/necrotizing cellulitis of the right fourth finger. He was started on antibiotics, cultured 
the wound, and was admitted and taken to the operating room for a surgical excision. The culture revealed 
Methicillin-resistant Staphylococcus aureus (MRSA). Over the next few days, antibiotics were changed and he 
required additional reconstruction surgery. Due to the severity of the infection, background comorbidity of 
diabetes increasing risk of the infection progression, the treating physician expected that the enrollee would 
require hospital services that would likely have crossed 2 midnights to be able to safely treat him.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from March 27, 2022, through April 1, 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 the testing (83789) provided on June 9, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says without an 
accompanying narrative on the claim form, the results listed in the record are not clearly aligned with the 
procedure codes submitted on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the testing (83789) provided on June 9, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for femoral pseudoaneurysm after recent Transcatheter aortic valve replacement (TAVR). 
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prothesis endoskeletal knee-shin system 
(code L5859). 
 
You asked the Plan to pre-approve endoskeletal knee-shin system. You say that you desperately need the 
advanced foot/knee. The Plan denied your request. The Plan says you do not meet criteria for this component 
because you have no condition that impairs K3 level function with the use of a microprocessor controlled knee 
alone. 
 
The Plan follows Medicare rules. Medicare rules state that endoskeletal knee-shin systems are only covered if 
certain criteria are met. 
 
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 endoskeletal knee-shin system. Our 
reviewer says that you do not meet the Medicare criteria for the requested endoskeletal knee-shin system. Our 
physician reviewer found the documentation indicates you are a K3 functional level ambulator, but does not 
support a need for the upgraded knee/foot with a microprocessor over the authorized mechanical 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 endoskeletal knee-shin system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lower limb prothesis endoskeletal knee-shin system (code L5859).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (E0627, E0260, E0265) and sales tax (S9999) provided from August 6, 2021, to August 23, 2021.
You asked the Plan to pay for the durable medical equipment and sales tax. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the provider is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program. The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (E0627, E0260, E0265) and sales tax (S9999) provided from August 6, 2021, to August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued inpatient psychiatric hospital care provided from 
May 11, 2022, to May 16, 2022. 
 
You asked the Plan to pay for continued inpatient psychiatric hospital care. The Plan denied your request. The 
Plan says the enrollee could receive continued care at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric hospital care. 
Our reviewer says that continued inpatient psychiatric hospital care is not medically necessary. Our physician 
reviewer found that based upon review the records provided it was not expected this enrollee would improve in 
a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or 
others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats 
of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any 
suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. This enrollee did not 
require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to 
himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon 
review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of  May 11, 2022 forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for continued inpatient psychiatric hospital care provided from 
May 11, 2022, to May 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee can receive the care needed in the 
hospital where they are now and there is no need for transfer to an LTACH. 
 
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 the enrollee appears to still be somewhat unstable and requires short-term additional 
acute care services that can safely be provided at the current facility until more stable for transfer. The enrollee 
does not require services at the LTACH that are not already available at the current facility. Transfer to the 
LTACH is not medically necessary as the enrollee is currently unstable and as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 2, 2021, and billed under codes 25040, 25280, 73110, and 76000.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the codes billed have an inclusive billing relationship and cannot be billed separately. Maximus overturned the Plans denial stating the coding edits referred to were not found. The Plan requested a reopen and provided further references to the billing issues outlined in the National Correct Coding Initiative Policy Manual for Medicare Services, Revision Date: 1/1/2021.
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. Based on the regulations provided, codes 73110, 76000, 254040 and 25280 are included in the billing of code 25609 which was also billed on the claim and cannot be billed separately without the appropriate modifiers. Those modifiers were not included on the claim submitted. In addition, there are more appropriate codes available for the billing of these services. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on November 2, 2021, and billed under codes 25040, 25280, 73110, and 76000.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings. 
 You asked the Plan to pre-approve compression stockings. You say that this equipment is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when 
they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and 
gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for chiropractic services provided to the enrollee on May 17, 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 enrollee had exhausted their 30 non covered service visits for chiropractic care. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan contract states that 30 visits are covered for 
services other than those covered by Medicare. At the time of services, those supplemental visits were 
exhausted. The records show that the service at issue is not manual manipulation of the spine. Therefore, we 
decided that the Plan does not have to pay for chiropractic services provided to the enrollee on May 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Infed. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug, Infed. The reviewer found that there is no 
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).