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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 October 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 6, 2022, to 
January 12, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says 
the DRG submitted on this claim is not supported by the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with acute kidney failure with tubular necrosis (N17.0). 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis is not supported in the medical record. Our physician 
reviewer found that the enrollee with prior traumatic brain injury, advanced dementia, and diabetes type 2 was 
treated in the hospital. He presented with worsening agitation and confusion. He was found to have diabetic 
ketoacidosis. He had an elevated creatinine, meeting the criteria for acute kidney injury, which improved with 
fluids and treatment for diabetic ketoacidosis (DKA). However, there was no record of the enrollee having had 
a urine test to measure for casts, sodium and/or creatinine to help describe acute tubular necrosis (ATN) 
clinically. The urine testing is required to diagnose ATN. Therefore, the diagnosis of acute kidney failure with 
tubular necrosis (N17.0) is not sufficiently supported according to the provided records.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 6, 2022, to January 12, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs an IRF admission due to weakness 
and decreased balance. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary. 
 
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 conditions appear improved on stable medications with no 
issues that appear to require a physicians evaluation three or more times per week in a hospital setting.         While the enrollee may require physical therapy and occupational therapy services, the medical records 
provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. The 
medical records do not clarify that treatment at the skilled nursing facility level is not appropriate 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from May 11, 2021, to May 21, 2021.
You asked the Plan to pay for skilled nursing facility services You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the claim was submitted with billing errors based on the Medicare guidelines. Maximus overturned the Plans denial for insufficient information in the case file regarding the denial. The Plan requested a reopen and provided additional information. The Plan noted that the billed "PAPD1" on the claim is not listed as a valid "HIPPS" code on the Code Master List from the CMS website, making it an invalid submission. The Plan demonstrated per the crosswalk table in the Patient-Driven Payment Model, the first digit of the HIPPS code billed by the provider was P, which indicates physical therapy or occupational therapy (PT/OT). For Payment group "TP", the third digit of the HIPPS code billed by the provider was "P", which indicates Nurse Payment group "CBC1". Per the Patient Driven Payment Method (PDPM) Case Mix Group Combinations, # 3: TP can only be billed with Nursing group codes CA2, CA1, BAB2, BAB1, PA2, and PA1. The provider used nursing payment group CBC1, which is not allowed.
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 codes and in cased of skilled nursing facility services, these codes must be in the appropriate sequence.
In this case, the claim submitted has errors preventing payment due to the type of code billed and the position or sequence of the code billed Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from May 11, 2021, to May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided on November 19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the claim was submitted with an inappropriate diagnosis code. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional claim information regarding the denial. The Plan demonstrated this claim denied because this service was billed inappropriately. The Plan notes the provider billed this service with Diagnosis Code Z53.9 defined as "Procedure and treatment not carried out, unspecified reason." That Plan states that the ICD-10-CM Official Guidelines for Coding and Reporting Manual, Section F states, when the original treatment plan is not carried out, the claim should show or sequence the principal diagnosis for the condition, even though treatment may not have been carried out due to unforeseen circumstances. Therefore, in this case the primary condition should be the primary diagnosis.
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 diagnosis codes. In this case this claim could not be paid due to an error with the primary diagnosis code reported.
The Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for a second session of anesthesia services provided to the enrollee on October 21, 2021.
You asked the Plan to pay this claim. 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 for insufficient information in the case file. The Plan requested a reopen and provided additional claim information. The Plan states review of the claims system shows two separate anesthesia/operative sessions on this date. The provider only submitted records for one session. The Plan provided documentation to show several requests were made by the Plan to the provided to submit records supporting the second session. Those requests were not responded to. The Plan agrees two sessions were provided, however records to support the services billed for each session were not provided.
The Plan provided documents to show one claim was paid for one session of anesthesia provided as the records supported the services billed. The claim number for this appeal remains denied for a lack of records submitted by the provider to support the second session billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must submit medical records to support the services billed. In this case, at the time of the appeal, the provider failed to submit the medical records required to support billing of the second anesthesia session. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.

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 documentation shows functional impairments however there are no active medical
comorbidities or complex functional deficits specified thus the complexity of the enrollee's documented
nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with
an interdisciplinary approach to rehabilitation care. Additionally, documentation shows poor tolerance of
therapy evaluations, and the enrollee would not be expected to tolerate 15 hours of therapy per week.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from
December 2, 2021, to December 16, 2021.
You asked the Plan to pay for home health services. You say that these services were medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the
Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional
medical records and information regarding the denial. The Plan notes this claim denied due to contradictory
information coded on the "SOC OASIS", which is compared to the Occupational Therapy Evaluation
completed on November 1, 2021, which is in the 5-day window. The Plan shows "SOC OASIS" coding
indicates a response of 2 for M1820 Ability to dress lower body and a response of 3 for M1830 bathing.
However, the Occupational Therapy Evaluation indicates independent in lower body dressing and independent/
SBA in bathing self/tub transfer. The Occupational Therapy Evaluation stated independent, which is
significantly different than the codes submitted on the "SOC OASIS. These inconsistencies in the records
provided versus what was provided in the coding system prevented the claim from being paid as billed.
The Plan is correct in the case. The Plan must follow Medicare rules. The rules say that home health care
services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A
doctor must certify the need for home health care services. The medical records provided must support the
services billed. In this case the information submitted shows inconsistent information regarding the enrollees'
abilities. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to pay for
the home health services provided to the enrollee from December 2, 2021, to December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on April 21, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan provided documentation showing code 93042 was upheld correctly as procedure code 99291 (column A) has a CCI conflict (Modifier 0=not allowed) with code 93042 (column B). Per Medicare billing rules, the Correct Coding Modifier Indicator (CCMIs) column, shows whether an NCCI PTP-associated modifier allows the PTP code pair to bypass the edit. If the indicator is 0, it means that no modifiers associated with NCCI allow you use this PTP code pair. When no modifiers are allowed, only the Column 1 code will be paid for the same patient on the same day.
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 codes.
In this case, this claim could not be paid as billed due to the coding and/or conflict issue with codes 9042 and 99291. Medicare rules for payment of this claim were not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on April 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation (A0427) and
ground mileage (A0425) provided to the enrollee on December 2, 2021.
You asked the Plan to pay for the ambulance services. You say that the enrollee's transport was emergent and
would not be included in the skilled nursing facility billing and/or inpatient stay billing. The Plan denied your
request. The Plan says that these services are not covered when the enrollee is inpatient.
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital the
movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service.
We looked at the file and Medicare rules. The file indicates the enrollee was inpatient when the ambulance
transport was provided.
Based on this information, we decided that Medicare rules for coverage of the ambulance services have not
been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation
(A0427) and ground mileage (A0425) provided to the enrollee on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
right reverse total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a right reverse total shoulder arthroplasty. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acroiliac (SI) joint injections. 
 
You asked the Plan to pre-approve the acroiliac (SI) joint injections. You say that the service is medically 
necessary. The Plan denied your request. The Plan says you have not failed conservative therapy and 
noninvasive treatments. 
 
The Plan follows Medicare rules. Medicare rules say that acroiliac (SI) joint injections is covered when criteria 
in Medicare Rules section is met. 
 
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 acroiliac (SI) joint injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation on physical examination of three (3) or more positive tests results. The clinical value and 
effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have 
not been demonstrated in the peer-reviewed literature. 
 
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 acroiliac (SI) joint injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the acroiliac (SI) joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
3, 2022.