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 need physical, occupational and speech therapy 
at a SNF level. You state that you did not receive any at the hospital because the staff believed you had 
shingles and were never evaluated for therapy at a SNF level. The Plan denied your request. The Plan says your 
request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an 
inpatient only status. The Plan states the services you require can safely be received at a different setting, for 
example, home with home health, in residential care, or home with close follow-up with your doctor. 
 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 you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to 
be functioning at/near your baseline. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 29, 2020.

You asked the Plan to pay for the lab 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 the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on June 29, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (75743) provided on April 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 75743 
is a column II code to column I code 37184. 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 the services (75743) provided on April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional PT visits for pelvic floor constipation. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional PT visits.  Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested pelvic floor therapy is not generally accepted as specific and effective therapy for your condition listed by the treating medical provider. 
The nurse practitioner referral lists a diagnosis of constipation. The records do not demonstrate that the unique 
skills of a professional therapist are required to safely and effectively provide treatment, that the services can 
be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The 
requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of 
a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or 
to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional PT visits for pelvic floor constipation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis (20610) provided on April 23, 2021. 
 
You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration because you were 
told that you would pay the same for in and out-of-network services. The Plan denied your request. The Plan 
says diagnosis code M70.60 is mismatched to the procedure modifier on the claim line. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 20610 is not supported in the record. Specifically, this claim was billed with a diagnosis 
code for an unspecified side and a bilateral modifier. This diagnosis code is mismatched to the procedure 
modifier on the claim. Based on this information, we decided that Medicare rules for coverage of the 
arthrocentesis have not been met. Therefore, we decided that the Plan does not have to pay for the 
arthrocentesis (20610) provided on April 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says San Bernardino County is outside of the plan's service area. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. The plan's rules state that home health services 
must be received within the plan's area. 
 
The case file shows that your current temporary address is outside of the plan's service area in San Bernardino 
County. Home health services cannot be approved at this location. 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 home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periapical first radiographic image (D0220) and a 
periapical additional radiographic image (D0330). 
 
You asked the Plan to pre-approve a periapical first radiographic image and a periapical additional radiographic 
image. You say that you have submitted additional medical records after the originating organization 
determination. The Plan denied your request. The Plan says any services provided that are over the frequency 
limit are not covered. The Plan also says that the enrollee met the yearly benefit allowance. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a periapical 
first radiographic image and a periapical additional radiographic image once every calendar year.  We looked at the file and Medicare rules. The records show that you received a periapical radiographic image 
and a periapical additional radiographic image on April 20, 2021, therefore, you have exhausted your 
maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a 
periapical first radiographic image and a periapical additional radiographic image have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a periapical first radiographic image (D0220) 
and a periapical additional radiographic image (D0330).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on January 4, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 
 
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services provided on January 4, 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 does not meet 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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 inpatient rehabilitation facility (IRF) admission and services.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to 
be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be 
received at a different setting, for example, home with home health, in residential care, or home with close 
follow-up with your doctor. 
 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 you do not qualify for SNF coverage. The 
enrollee does not have documented skilled nursing needs. You do not have documented skilled therapy needs. 
You do not have a documented decline in function. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of your condition. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that you need to use a reputable surgeon and feel that 
this provider will do a great job for you. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the plan and you can be 
treated by an in-network plastic surgery specialist. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(S9986). 
 
You asked the Plan to pre-approve the special supplemental benefits. The Plan denied your request. The Plan 
says you do not have any of the eligible medical conditions that would qualify you for coverage. The Plan also 
says that you do not have a high risk of hospitalization or other results adverse for the health, and do not 
require intensive care coordination. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the special supplemental benefits have not been met. Specifically, we have confirmed that you do 
not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan 
does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says that the rules for SNF care have not been met. 
 
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 SNF 
care is medically necessary and reasonable for your condition. Our physician reviewer found you are an 80-
year-old female with a past medical history of hypertension who presented to the acute hospital on October 30, 
2021, with a complaint of headache and high blood pressure. You were treated in the hospital with intravenous 
fluids and antibiotics for hyponatremia, a urinary tract infection with bacteremia and your condition improved. 
She was also treated for uncontrolled diabetes mellitus with glimepiride and insulin. While you do not require 
skilled therapy services, you do require skilled nursing services, i.e., intravenous Rocephin once daily. Based 
on the medical records provided daily skilled nursing services are required for the intravenous antibiotics. You 
do require the services on an inpatient basis, in a SNF setting, for the duration of the intravenous Rocephin 
administration. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for services billed under Claim A for codes 87086 and
87186 for September 18, 2020.
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 Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says that Claim A denied because this
service was previously paid under another claim. The correct billing of this service needed to include modifier
59, to distinguish the claim as a separate and distinct service.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that providers may bill
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.
The claim submitted cannot be paid due to the omission of a modifier that would show it to be a separate and
distinct service from those previously billed. Medicare billing criteria are not met. Therefore, we decided that
the Plan does not have to pay services billed under Claim A for codes 87086 and 87186.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on May 17, 2021. 

You asked the Plan to pay for the physical therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the clinical documentation 
supports these clinical findings and medical necessity for the procedure. The Plan denied your request. The 
Plan says this item is considered experimental and investigational. There is insufficient evidence of its 
effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at 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 (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub. 
 
You asked the Plan to pre-approve a walk-in tub. You say that a walk-in tub is medically necessary. The Plan 
denied your request. The Plan says a walk-in tub is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower and bath equipment of any type are not 
covered because they are not primarily medical in nature. While a walk-in tub may be appropriate in this case, 
neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to 
pre-approve a walk-in tub.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sacroiliac joint injection (27096) provided on June 18, 
2020. 
 
You asked the Plan to pay for a sacroiliac joint injection. You say that this was billed correctly. The Plan 
denied your request. The Plan says this requires a modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that claims which contain CPT codes describing services performed on anatomic structures that can be distinguished as left or right 
require laterality modifiers. Claim lines for CPT codes requiring use of the RT and LT modifiers, submitted 
without the RT and/or LT modifiers or with the RT/LT on a single claim line will be rejected as incorrect 
coding. 
 
We find that CPT code 27096 is not supported in the medical record. Specifically, this service can be 
performed on the right, left, or bilaterally and was not billed with a modifier to indicate laterality. Based on this 
information, we decided that Medicare rules for coverage of a sacroiliac joint injection have not been met. 
Therefore, we decided that the Plan does not have to pay for a sacroiliac joint injection (27096) provided on 
June 18, 2020.