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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as home health. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a shank foot system with vertical loading pylon
(L5987), a multi- axial rotation unit (L5986), a flexible protective outer surface covering system (L5962) and
below knee, molded supracondylar suspension (L5670) for the enrollee.
You asked the Plan to provide coverage for replacement prosthetic components. The Plan denied your request.
The Plan says original denial stated the codes in question were either still under warranty or exceeded the
enrollees needs based on Medicare coverage criteria. Maximus overturned the Plans denial. The Plan requested
a reopen and stated requested components are replacing current components used by the enrollee that are still
under warranty. It should be noted that the Plan did not include the warranty information in the original case
file that would have allowed Maximus to confirm the original denial for that reason was supported.
As the Plan has now provided the applicable warranty information, we find the Plan is correct in this case. The
Plan must follow Medicare rules. The rules say that if equipment or a device can be replaced free of charge by
the warrantor, no program payment may be made by the Plan. The warranty information submitted shows that
at the time of the appeal, the warranty for the items stated to need replacement was still in place. Therefore, we
decided that the Plan does not have to provide coverage for a shank foot system with vertical loading pylon
(L5987), a multi- axial rotation unit (L5986), a flexible protective outer surface covering system (L5962) and
below knee, molded supracondylar suspension (L5670) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary and 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 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extracranial-intracranial arterial bypass procedure for
the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the service has not been demonstrated to be any more effective
than no surgical intervention.
Our Medical director looked at the case file and the reopen request. At issue is coverage for an extracranialintracranial
arterial bypass procedure. Our Medical director says that the enrollee has Moyamoya disease and
has had two strokes and that extracranial-intracranial arterial bypass surgery to improve the blood supply to the
brain and reduce the risk of having a stroke has not been demonstrated to be any more effective than no
surgical intervention. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for these services.
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 an extracranial-intracranial arterial bypass procedure for the enrollee.
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 at the time of the appeal, IRF care was medically
necessary. The Plan denied your request. The Plan says the 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services.
The Maximus Physician Reviewer determined this care to be reasonable. The Plan requested a reopen and
argued your medical needs did not meet criteria for the acute rehab level of therapy or for the medical
complexity component. The Plan further notes that the recommended a skilled nursing facility.
The medical records show you had a history of hypertension, Alzheimer's disease, and acute kidney injury,
who suffered a right hip fracture and broken ribs in a fall, as well as a pneumothorax which required a chest
tube. It was documented that you would require physical assistance for mobility. The Plan is correct in this
case. The documentation does not support that the complexity of your nursing, medical and rehabilitation needs
required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatments. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare. 
 
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 services. Our physician 
reviewer found that the Vertiflex device is experimental. More research is needed to determine the safety and 
efficacy of the device. Therefore, the request is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 there are no complex nursing or rehabilitation needs. Medically necessary care 
can be provided in a different level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76775) provided on May 11, 
2022. 
 
You asked the Plan to pay for the retroperitoneal ultrasound. You say that this claim has not been paid in full or 
under the terms of the contract for the services provided to the enrollee. The Plan denied your request. The Plan 
says with the information provided, it cannot be determined whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the retroperitoneal ultrasound have 
been met. Medical records were not provided with this case. The record shows that the Plan made multiple 
attempts to obtain this information, but it was not received. Without this information, we cannot determine if 
the service provided was medically necessary. Therefore, we decided that the Plan does not have to pay for the 
retroperitoneal ultrasound (76775) provided on May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 does not have complex nursing or rehabilitation needs. Medically 
necessary care can be provided in a different level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 7, 2022, billed with 
codes 81201 and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one Current Procedural 
Terminology (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 NGS 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 
February 7, 2022, billed with codes 81201 and 81317.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided from February 16, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was not under hospice on the 
dates of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 6, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the nursing facility 
care provided from February 16, 2022, to February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of syncope. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an implantable loop recorder have not been met. Specifically, there is no diagnosis of syncope. 
Therefore, we decided that the Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on March 2, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee had two separate transports on 
the date of service in this case. You also say that this should be covered. The Plan denied your request. The 
Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on March 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from August 22, 2021, to 
August 27, 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 you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 diagnosis code G93.41, defined as metabolic 
encephalopathy. 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 documentation does not support the diagnosis 
code billed for the services rendered. Our physician reviewer found the enrollee was admitted and treated in the 
hospital for a urinary tract infection and cellulitis requiring antibiotics. The records described the enrollee as 
confused. The enrollee was alert but confused even after days of successful treatment. The opinion of the 
treating physician was that the enrollee was sundowning (dementia) at baseline. This suggests that there was 
insufficient support found in the documentation for using the diagnosis of metabolic 
encephalopathy. Therefore, this diagnosis code is not supported by the documentation.  
 
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 from August 22, 2021, to August 27, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10005 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 10005. The Plan denied your request. The Plan says payment for 
code 10005 is bundled into payment for code 20206. 
 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 10005 
is a column II code to column I code 20206. 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 10005 billed for date of service June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more therapy and would benefit 
from rehab in an IRF. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 enrollee does not require the intensity of services provided at an IRF. The 
enrollee's care needs can be met at a lower level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on April 12, 
2022. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that the enrollee had multiple 
exams on this date of service and the attached reports support the level of service. You say that the claim 
should be reconsidered for processing. The Plan denied your request. The Plan says procedure code 99153 
remains denied. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor.  Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided 
on April 12, 2022.