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 requires physical therapy to work on 
increasing strength, endurance, functional mobility, durable medical equipment management, work on gait, 
transfers, safety balance, and stairs. You say that the enrollee requires close physician oversight to closely 
manage their neurological function and kidney functions which cannot be provided at a lower level of care. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs 
can be met at a lower 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
spondylosis without myelopathy or radiculopathy of the lumbar region and vertebrogenic low back pain. There 
are multiple plausible pathologic sources of significant pain generation. The back pain, pain with flexion and 
extension, positive sacroiliac (SI) distraction, Fortins finger, and SI compression are all non-specific to any 
pathologic entities. Moreover, the formal magnetic resonance imaging (MRI) report does not corroborate 
Modic changes at the requested level. The records do not support that the Intracept procedure is reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99072 and 99001 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee's undiagnosed problem required a 
work-up. The Plan denied your request. The Plan says that incorrect coding was identified. 
 
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. 
 
We looked at the file and the rules. The Plan denied the services at issue due to incorrect coding. However, the 
Plan did not show what guidelines were not met that would warrant a denial of payment. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Therefore, we decided that the Plan has to pay for procedure codes 99072 and 99001 billed for 
date of service July 26, 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: 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 meets the criteria for an IRF admission. 
The Plan denied your request. The Plan says the enrollee does not require the medical monitoring of a 
rehabilitation physician, and the enrollee's needs can be met at a lower 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 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 is presently receiving appropriate services in the acute care 
setting. Continued care in the acute hospital is appropriate until the enrollee is stable to transfer to a lower level 
of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or 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 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 pre-approve insertion of an interlaminar/ interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of an interlaminar/ interspinous process stabilization/distraction 
device. 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 insertion of an interlaminar/ 
interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found interlaminar devices 
are experimental in spine surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an interlaminar/ interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an 
interlaminar/ interspinous process stabilization/distraction device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Positive Airway Pressure (CPAP)
machine (E0601) and a heated humidifier (E0562).

You asked the Plan to pre-approve a CPAP machine and a heated humidifier. You say that the services are
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria
has not been met.

The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document
that the beneficiary is benefiting from PAP therapy.

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 CPAP machine and a heated
humidifier. Our reviewer says that the services are not medically necessary. Our physician reviewer found
based on the medical records provided there is no documentation that the CPAP device at issue in this case
meets all of Medicare's LCD criteria for medically reasonable and necessary for you. Provided records do not
document an in-person clinical re-evaluation by the treating practitioner with documentation that symptoms of
obstructive sleep apnea are improved; and objective evidence of adherence to use of the CPAP device,
reviewed by the treating practitioner. Adherence to therapy is defined as use of CPAP =4 hours per night on
70% of nights during a consecutive thirty (30) day period.

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 CPAP machine and a heated humidifier have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Continuous Positive Airway Pressure (CPAP) machine
(E0601) and a heated humidifier (E0562).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6241) for tooth #12 and retainer crowns
(D6751) for tooth #'s 11 and 13.

You asked the Plan to pre-approve a pontic and retainer crowns. You say that the only way to replace tooth #12
is with a bridge. The Plan denied your request. The Plan says these services are not medically necessary.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a pontic and
retainer crowns when the services are medically necessary and reasonable.

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 pontic and retainer crowns. Our
reviewer says that the documentation provided does not meet the criteria for coverage for a fixed bridge
replacing tooth #12. Our physician reviewer found a fixed bridge may be covered to replace a single maxillary
anterior tooth if there are no missing maxillary posterior teeth. Our reviewer found in this case, tooth #12 is a
posterior tooth and there are additional missing maxillary teeth bilaterally. Our physician reviewer also found
that there was no indication that a removable appliance was contraindicated.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a pontic and retainer crowns have not been met. Therefore, we decided that the
Plan does not have to pre-approve a pontic (D6241) for tooth #12 and retainer crowns (D6751) for tooth #'s 11
and 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis (eo), with adjustable position locking 
joint(s), prefabricated, off-the-shelf provided to the enrollee on July 21, 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 documentation submitted does not sufficiently support the billed supply code. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no physician order evident in the records for this orthosis. The documentation does not show 
medical necessity. 
 
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 pay for an elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf 
provided to the enrollee on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for a prosthesis with a K3 foot does not meet the Medicare criteria as 
reasonable and necessary. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a K2 ambulator. The enrollee is not a typical community ambulator. 
 
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 a prosthetic leg with an advanced foot feature.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on November 4, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan notes the claim was billed with a place of service (POS-81) inconsistent with Medicare rules. An independent laboratory taking a sample in its laboratory shows "81" as place of service. There is no documentation that the specimen was taken by the laboratory directly. The difference between date of collection (November 4, 2021) and date received (November 6, 2021) confirms that this was not taken by the laboratory directly. In addition, the test was billed without the required DEX Z-code or unique test identifier code.
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 code. In this case, this claim could not be paid as billed due to inconsistent dates of service reported and the omission of the required identifier codes. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (64628).

You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary.
The Plan denied your request. The Plan says this procedure is investigational and non-covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is insufficient documentation to show that the spinal vertebral bodies are the
primary generators of the enrollee's chronic persistent pain.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223-57 billed for services provided on June 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the consult was the decision for surgery. The 
Plan denied your request. The Plan says that the code is included in the payment for code 93286. 
 
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 CPT code 99223-57 is supported. There are no code edits between code 99223 and 93286. The 
medical records show that the E&M visit billed with the 57 modifier was the visit in which the provider 
decided to perform the surgical procedure, 33208. Based on this information, we decided that Medicare rules 
for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure 
code 99223-57 billed for services provided on June 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on June 24, 2021. 
 
  You asked the Plan to pay for the rotary wing air transport and mileage. You say that the air ambulance 
transport was emergent, medically necessary, and the most appropriate method of transportation to an 
appropriate facility. The Plan denied your request. The Plan says there is no documentation that the enrollee's 
condition was such that the time needed to transport them by ground, or the instability of transportation by 
ground, posed a threat to the enrollee's survival or seriously endangers their health. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport and mileage. 
Our physician reviewer found while transfer of the enrollee was medically necessary and reasonable, use of an 
air ambulance was not. Our reviewer also found that given the time of year, time of day and distances involved, 
the enrollee could have been safely and rapidly transferred by ground ambulance. 
 
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 rotary wing air transport and mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage 
(A0436) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility discharge day management provided to the 
enrollee on October 4, 2021. 
 
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 Current Procedural Terminology (CPT) code 99316 remains 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 99316 is "Nursing facility discharge day management; 
more than 30 minutes." 
 
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 documentation does not 
include medical record to confirm a discharge management service has been performed. After careful review of 
submitted documentation, a medical record of service billed was not found to be included, and therefore cannot 
be verified.  
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 nursing facility discharge day management provided to the enrollee on October 4, 2021.