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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting transfer from an inpatient 
rehabilitation facility to a SNF. You say you cannot walk and need to go to a SNF. The Plan denied your 
request. The Plan says the SNF services you are requesting do not meet the requirements for approval. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are receiving an appropriate level of care within the inpatient rehabilitation 
facility. There is no medical necessity for transfer. Your chronic medical and therapy needs are being met. You 
are receiving appropriate post-acute services and have not completed a course of therapy. You do not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 63053 provided on June 28, 
2022. 
 
You asked the Plan to pay for the medical services coded 63053. You say that the medical records support 
payment for the services as billed. The Plan denied your request. The Plan says the documentation does not 
support payment for code 63053 as it is not supported in the medical documentation submitted. 
 
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 63053 is Laminectomy, facetectomy, or foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or 
lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral segment (List 
separately in addition to code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the medical services coded 63053. Our reviewer says that the 
documentation does not support payment for CPT code 63053 as billed. Our reviewer found that the operative 
report does not include sufficient documentation to confirm Laminectomy, facetectomy, or foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or 
lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral segment has 
been performed per National Correct Coding Initiative Policy. The operative report documents that "At this 
time using high-speed burr and Kerrison punch, decompressive laminectomy and partial facetectomy as well as 
bilateral foraminotomy were performed...On the right-hand side a complete facetectomy was required to 
adequately decompress the neural element. Tracing it out of harm's way using a 15 blade an annulotomy was 
performed. Using a series of curettes, pituitaries, rasps and ronguers complete diskectomy from endplate to 
endplate all the way down to the anterior longitudinal ligament.  In this case, CPT 63054 cannot be verified 
with the documentation submitted. 
 
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 medical services coded 63053 have not been met. Therefore, we decided 
that the Plan does not have to pay for the medical services coded 63053 provided on June 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 20, 2022, to 
June 22, 2022. 
 
You asked the Plan to pay for the home health 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 as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that the NOA was submitted with the 
incorrect admission date. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from June 20, 2022, to June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this device is not covered 
by Medicare or the Plan. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the requested Zilretta is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Triamcinolone Acetonide first. 
 
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 Zilretta. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug. Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve repairs for a Group 3 power wheelchair (PWC). 
 
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 that the repairs are not covered because the Group 3 power wheelchair is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the repairs are not covered because the PWC is not 
medically necessary; however, no medical records were received for review. MAXIMUS requested records 
from the Plan but a response was not received. Without medical records, a determination based on medical 
necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve repairs for a Group 3 
power wheelchair (PWC).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
 
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 office visit provided on August 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient therapy provided from July 14, 
2022, to July 29, 2022. 
 
You asked the Plan to waive the copayment for outpatient therapy. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for in -network outpatient rehabilitation services/occupational services.  
 
You have been asked to pay a $40 copayment for outpatient therapy. The total allowed amount for outpatient 
therapy is $200. However, you are being asked to pay $175 which is less than the required amount. This 
item/service falls within the in -network outpatient rehabilitation services/occupational services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient therapy provided from July 14, 2022, 
to July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the records provided support the 
need for the requested device. The Plan denied your request. The Plan says this type of system is unproven and 
not medically necessary. The Plan says that large well-designed studies in the peer review scientific literature 
comparing stand-alone use of Superion device to established surgical decompression are needed. 
 
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 a Vertiflex Superion device. Our 
reviewer says that a Vertiflex Superion device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found a Vertiflex Superion device is experimental, and more research is needed. 
 
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from September 16, 2020, to September 28, 2020. 
 
You asked the Plan to waive the copayments for the physical therapy (PT) services. You say that you feel you 
should not be billed two years later. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physical, occupational, or speech therapy visits.  
 
You have been asked to pay a $25 copayment for each of the physical therapy (PT) services, for a total of $75. 
This item/service falls within the physical, occupational, or speech therapy visits benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for physical therapy (PT) services provided from September 16, 2020, 
to September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pathology service provided on July 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pathology. You say that the records attached support the services. The Plan 
denied your request. The Plan says you must receive your care from an in-network provider. 
 
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 a pathology service provided on July 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that based on 
Medicare guidelines and the information we have about the enrollees condition they do not meet all the 
requirements. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee has comorbidities and hospital complications and would be expected to require continued 
hospitalization during rehabilitation with an interdisciplinary approach to care. Clinical documentation shows 
that the enrollee has complex functional impairments along with mobility and self-care deficits. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office specialist visit provided on August 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for office specialist visit. You say that you are a credentialed provider. The Plan 
denied your request. The Plan says there are no referrals on file for the services. 
 
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 an office specialist visit provided on August 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on August 08, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 surgery provided on August 08, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease panel testing provided on March 2, 
2022. 
 
You asked the Plan to pay for the infectious disease panel testing. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infectious disease panel testing have not been met. Specifically, the records show that a single 
panel was ordered and performed on a single specimen, but this service was billed by reporting individual components with multiple procedure codes. Therefore, we decided that the Plan does not have to pay for the 
infectious disease panel testing provided on March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 49020-78-59 provided on January 
14, 2022. 
 You asked the Plan to pay for the medical services coded 49020-78-59. You say that you would like this claim 
reprocessed and approved for separate payment. The Plan denied your request. The Plan says the 
documentation does not support the use of modifiers to bypass the NCCI edit. 
 
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 49020 is a column II code to column I code 47600; however, 49020 
was billed with a modifier.  
 
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 medical services coded 49020-78-59. Our reviewer says 
that the documentation does not support the services as billed. Our reviewer found that per NCCI edits, there is 
a bundled relationship between CPT 49020 and 47600. However, a modifier is allowed to unbundle these 
services, provided the medical records validate the use of the modifier. In this case, the medical records do not 
validate that CPT 49020 was performed as a separate/distinct service, unrelated to CPT 47600, therefore, it is 
inappropriate to use a 59 modifier and no additional reimbursement is allowed for this code. 
 
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 medical services coded 49020-78-59 have not been met. Therefore, we 
decided that the Plan does not have to pay for the medical services coded 49020-78-59 provided on January 14, 
2022.