Persius/hicric huggingface dataset:
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 it is felt that LTACH would be the best 
option for the enrollee at this time. The Plan denied your request. The Plan says the current facility is able to 
meet the enrollee's needs. 
 
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 is a female who was admitted to the facility due to acute on chronic 
respiratory failure, and acute heart and renal failure. Recent notes describe the patient as receiving high flow 
oxygen during the day, bilevel positive airway pressure (BiPAP) at night, and ongoing diuresis and antibiotics 
for urinary tract infection. She still requires treatment for anemia, and blood transfusion is being refused. 
 
The patient appears to be more stable and gradually improving but requires short-term additional acute care 
services that can be safely completed at the current location until appropriate for transfer to a lower level of care. The patient does not require services at the LTACH that are not already available at the current facility. 
Transfer to LTACH is not medically necessary as it would not be clinically advantageous at this time. Transfer 
to a lower level of care may be considered when treatment is completed, and the patient is more stable.  
 
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 June 8, 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 the denied codes are inclusive to other codes. 
 
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 the denied codes is: 
 
CPT 36215: 
 
Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a 
vascular family 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation  
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 in terms of CPT 36215, the operative 
report does not include enough documentation to confirm a suspected arterial inflow problem separate from the 
peripheral dialysis segment is suspected, and the selective catheter is advanced from the dialysis circuit 
puncture beyond the peri-anastomotic segment into the inflow artery. In terms of CPT 75710, this procedure 
would be covered if CPT 36215 was supposed. 
 
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 surgical services provided to the enrollee on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 13, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until January 31, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a speech generating device (E2510) provided June 9, 2021. 
 
You asked the Plan to pre-approve the device. You say that the device was medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Speech generating devices may be covered if the 
patient suffers from a severe speech impairment and that the medical condition warrants the use of a device. 
 
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 device. Our reviewer says that the 
device is medically necessary. Our physician reviewer found the record shows that the enrollee can use and 
benefit from the device and suffers from a speech impairment. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve a speech generating device (E2510) provided June 9, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF care. The Plan denied 
your request. The Plan says the enrollee does not meet guidelines for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic - porcelain/ceramic (D6245), and a retainer crown 
(D6740) provided by a participating provider on November 3, 2021. 
 
You asked the Plan to pay for a pontic - porcelain/ceramic and a retainer crown. You say that you would like 
the Plan to pay for this. You say that you fell and hit your tooth. The Plan denied your request. The Plan says 
the rendered dental work are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic - porcelain/ceramic (D6245), and a retainer crown (D6740) provided by a participating provider on November 3, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genomic sequence analysis screening panel provided to the 
enrollee on September 27, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this is a non-covered test, as it is unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient evidence to support the clinical validity and utility of FoundationOneHeme genomic 
sequencing. FoundationOneHeme has not been cleared or approved by the FDA. The documentation in the case 
file does not support that the FoundationOneHeme genomic sequencing would guide medical management in 
this case. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a genomic sequence analysis screening panel provided to the enrollee on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided to
the enrollee on April 09, 2021.
You asked the Plan to pay for these supplies. You say that this equipment was medically necessary for the
enrollee. The Plan denied your request. The Plan says all of the required Medicare criteria for coverage were
not met. Maximus overturned the Plans denial stating this equipment would be beneficial. The Plan requested a
reopen and stated that the argument was not medical necessity but the fact that all of the required criteria were
not met, and Medicare does not allow exceptions for coverage.
The Plan stated that based on the Medicare LCD rules, this equipment is considered medically reasonable and
necessary for members with diabetes who use insulin with a least three daily injections, perform frequent (four
or more times a day) testing, and require frequent self-adjustment of insulin dosage based on the blood glucose
testing results. The Plan stated the medical record documentation did not indicate the need for frequent selfadjustment
of insulin dosage; therefore, medical necessity is not adequately supported for the billed supply
code.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (85060) provided on November 23, 
2021. 
 
You asked the Plan to pay for code 85060. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
 
 We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an 
outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (85060) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand-held low vision aids (V2600) purchased on May 25, 
2021. 
 You asked the Plan to pay for hand-held low vision aids. You say that this service is necessary, and you would 
like reimbursement. The Plan denied your request. The Plan says this service is not covered by Original 
Medicare or your Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested items or services 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the hand-held low vision aids (V2600) purchased on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99220) provided on May 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is a more 
appropriate code that better represents the services performed. 
 
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 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. 
 Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. 
Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99220 is 
not supported by the records provided. Our reviewer found that while the case file contains documentation of a 
comprehensive history and a comprehensive physical examination, the documentation does not support medical 
decision making of high complexity. Documentation of a severe exacerbation of a chronic problem or an acute 
illness which threatened life or bodily function is not present in this case. 
 
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 the services (99220) provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
28, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit (G0439) provided on June 18, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for annual wellness visit. You say that the doctor's office sent the additional 
information that was requested so this should be paid. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 annual wellness visit (G0439) provided on June 
18, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D testing provided on October 5, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is 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 pay for the testing. 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 76-year-old female who presented for upper endoscopy which showed irregular 
margins in the gastroesophageal junction, hiatal hernia, erythema and congestion in the antrum compatible with gastritis and polyps in the stomach body. Review of the medical literature and clinical practice guidelines does 
not support the clinical utility of WATS 3D testing to predict cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the WATS 3D testing provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 the lab services provided on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical arthroscopy services provided to the enrollee on 
September 23, 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 the denied codes remain 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 the denied codes is: 
 
CPT 29806: 
 
Arthroscopy, shoulder, surgical; capsulorrhaphy 
 
CPT 29822: 
 
Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral 
articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, 
articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign 
body[ies]) 
 
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 in terms of CPT 29806, the shoulder 
arthroscopy procedure include a limited debridement, and therefore is not separately payable when another 
shoulder arthroscopy procedure is billed and paid on the same shoulder for the same day for the same 
beneficiary at the same encounter. In this case, all procedures were performed on left shoulder. In terms of CPt 
29822, the operative report does not support a capsulorrhaphy arthroscopy was performed due to a 
capsulorrhaphy defect, and therefore would be inclusive to the rotator cuff repair. The operative report 
describes attachment of torn labrum to capsule. 
 
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 surgical arthroscopy services provided to the enrollee on September 23, 2021.