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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens (V2782), U-V lens (V2755), anti-reflective coating
(V2750), and photochromatic tint (V2744) provided on March 26, 2022.
You asked the Plan to pay for these vision services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says these are not covered benefits. Maximus partially overturned the
Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the original
claim and Explanation of payment shows V2782 (digital aspheric lens) as submitted as part of the claim under
appeal. This was investigated by the vision provider during the health plan's appeal process and it was
determined that V2782 (digital aspheric lens) was not provided. This was clearly stated in the letter dated
May 5, 2022, which states per the provider office staff, you did not receive digital aspheric lens in hi -index but
a bifocal in impact -resistant lenses (polycarbonate). The original denial notice shows V2782 as a denied
service. Therefore, it went ahead and corrected the denial. A copy of the corrected denial letter was
submitted with the reopen. It shows code V2782 code was removed (as it was not provided] and the correct
lens code V2784 that was provided was correctly denied as not a covered benefit. The polycarbonate is a noncovered
lens enhancement service (V2784) and was available to you at a discounted rate. In addition, the vision
provider agreed that the service was not rendered and should have not been on the original claim.
The Plan is correct in this case. 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. Based on the Plan contract and the claim submitted by the provider,
these services were not covered at the time of service. Therefore, we decided that the Plan does not have to pay
for the lens (V2782), U-V lens (V2755), anti-reflective coating (V2750), and photochromatic tint (V2744)
provided on March 26, 2022.
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's condition worsened when placed into 
isolation due to COIVD-19 and meets the medical necessity portion and needs SNF care due to deceased 
functioning. The Plan denied your request. The Plan says the enrollee does not require daily skilled care that 
exceeds the scope of custodial care to be considered medically necessary. 
 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, of the sacroiliac joint, percutaneous or 
minimally invasive (27279). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous minimally invasive fusion/stabilization 
of the sacroiliac joint (SIJ) for the treatment of back pain is indicated for the treatment of SIJ pain for patients 
with low back/buttock pain who meet all of the criteria. 
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that the 
enrollee was being treated for sacroiliitis not elsewhere classified. He presented with low back pain. The pain is 
rated at 7/10. He notes significant improvement with all three of the sacroiliac joint injections. The exam 
reveals spinal and paraspinal tenderness. There is mild decreased bilateral side bend. Patricks test, Fortin 
finger, Gaenslens, and thigh thrust tests are positive bilaterally. However, the magnetic resonance imaging 
(MRI) of the lumbar spine dated February 6, 2023, did not rule out other potential causes of pain. The bilateral 
x-rays of the hips demonstrated mild degenerative arthrosis.  Moreover, the x-rays did not corroborate any significant pathology of the sacroiliac joints. Therefore, the 
enrollee does not meet criteria for coverage of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, of the sacroiliac joint, percutaneous or minimally invasive (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in average 
volume assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a bilevel 
positive airway pressure (BiPAP)device with average volume-assured pressure support (AVAPS) and a back-
up rate. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 43261 billed for dates of service 
from February 17, 2022, to February 24, 2022. 
 
You asked the Plan to pay for procedure codes 99223 and 43261. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the provided records do not support procedure 
code 99223. The Plan also says that payment for code 43261 is bundled into payment for code 43274. 
 
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 99223 is: Initial hospital 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 are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
Additionally, we have confirmed that code 43261 is a column II code to column I code 43274; however, code 
43261 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 procedure codes 99223 and 43261. Our reviewer says that 
procedure codes 99223 and 43261 do not meet criteria for payment. Our reviewer found that, per CPT 
guidelines for code 99223, 3 of 3 key components must be met or exceeded. In this case, the procedure report 
for the date of service billed does not include a comprehensive history. This level of service cannot be verified. 
The procedure report for code 43261 describes endoscopic retrograde cholangiopancreatogram (ECRP) with 
stent placement, and a biopsy was performed. Modifier XS, indicating a distinct service, is not supported in this 
case, as the procedure report does not support the biopsy was a separate procedure from the more 
comprehensive service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99223 and 43261 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 43261 billed for dates of service from 
February 17, 2022, to February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have segmental and somatic dysfunction of the cervical, thoracic, lumbar, and pelvic regions 
and a documented subluxation. The record provided does not document continued improvement or that clinical 
improvement can be reasonably expected from ongoing care. Therefore, the requested services are considered 
maintenance care and are excluded by the Medicare rule. The elements of the coverage criteria are not satisfied. 
The requested services are not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 5 additional chiropractic manipulative treatments.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel miles billed for date of service March 23, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the records do not include 
documentation of the miles traveled on the date of service at issue. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for travel miles billed for date of service March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service October 
11, 2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. Based on this 
information, we decided that Medicare rules for coverage of procedure code 85060 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service 
October 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (22869 
and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex spacer is experimental. 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 
the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex 
superion device placement surgery (22869 and 22870).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous spacer at the L4-5 levels, in this case, is not medically reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health treatment from March 2, 
2023-forward. 
 
You asked the Plan to pre-approve inpatient behavioral health treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient behavioral health treatment. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for March 2, 2023 forward as this 
enrollee was not shown to be a danger to herself or others. There were no auditory or visual hallucinations 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health treatment from March 2, 2023-forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, institutional type includes oscillating, 
circulating and stryker frame, with mattress (E0270). 
 
You asked the Plan to pre-approve an oscillating hospital bed. You say that the services should be covered 
because the enrollee is unable to get in and out of her own bed. She cannot lift her legs and needs the head of 
the bed elevated to about 90%. The Plan denied your request. The Plan says the requested hospital bed is 
specifically excluded from coverage as they are institutional equipment that are inappropriate for home use. 
 
The Plan must follow Medicare rules. Medicare rules say that oscillating hospital beds are not covered.  
 
While an oscillating hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage 
for this item. Therefore, we decided that the Plan does not have to pre-approve a hospital bed, institutional type 
includes oscillating, circulating and stryker frame, with mattress (E0270).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) services for the
enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee is high risk of developing
lymphedema, and use of ImpediMed's L-Dex device is medically necessary. The Plan denied your request. The
Plan says that the requested service is considered experimental and investigational, as it has not been identified
as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed
medical literature published in the English language.
Our Medical director looked at the case file and the reopen request. At issue is coverage for bioimpedance
spectroscopy (BIS) services. Our Medical Director states that the available evidence in the medical literature
and the clinical documentation in this case are insufficient to support that bioimpedance spectroscopy is
medically reasonable and necessary. Our physician reviewer found that the enrollee's condition does not meet
criteria for coverage of 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 bioimpedance spectroscopy (BIS) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87150) provided on May 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 87150 is "Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed". 
 
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 87150 is 
not supported by the records provided. Our reviewer found that the laboratory report does not include "Culture, 
typing". Per Codify "The lab analyst performs an analysis using amplified DNA or RNA probe technique on a 
previously isolated and identified organism to categorize the organism more specifically, such as to the 
taxonomic level of type". This description was not found in laboratory report. 
 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 (87150) provided on May 31, 2022.