Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's need for increased monitoring and management for their medical needs. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for 
transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a frenulectomy (D7960).
You asked the Plan to pre-approve these services. You say that you are appealing the denial. The Plan denied your request. The Plan says that this service is not a covered benefit under your dental plan. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a frenulectomy (D7960).
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 services are necessary for the enrollee to receive 
continued medical management for their medical needs. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 the enrollee does not need an intensive therapy program. While the enrollee may benefit 
from physical and occupational therapy, their rehab needs can be provided in a lower intensity and alternate 
setting such a skilled nursing facility.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing services. 
 
You asked the Plan to pre-approve the requested services. You say that you have family genes with breast 
cancer. The Plan denied your request. The Plan says the testing is excluded as a screening. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The testing at issue in this appeal is being requested for screening purposes. 
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have 
to pre-approve genetic testing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTAC 
admission criteria under CMS guidelines. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an LTACH care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 0031U, 0032U, and 0033U.
You asked the Plan to pay this claim. You stated these services should be covered by the Plan. The Plan denied your request.
The Plan states while a portion of this claim was paid, this type of testing panel should be billed using one code on the claim. Maximus upheld the Plans denial. A reopen was performed to give more clarification on the codes billed.
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 29, 2022, and billed under codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 0031U, 0032U, and 0033U.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a socket insert (L5655), Ottobock Trias foot (L5981, 
L5986). 
 
You asked the Plan to pre-approve the items. You say that the K3 foot will allow the enrollee to effectively 
transverse environmental barriers and continue to perform activities of daily living (ADLs) safely and with less 
energy expenditure. You say that the requested codes L5655 and L5673 are very different in their actual 
function and may be used independently of one another or in conjunction. The Plan denied your request. The 
Plan says an additional socket cannot be approved as a socket insert has already been approved. The Plan also 
says that there is no documentation showing why the current K3 foot, which is under warranty, will not meet 
the enrollee's needs. 
 
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 items. Our physician reviewer 
found a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the 
community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the 
documentation does not indicate the enrollee's current socket or K-3 level foot is not usable; therefore, a 
replacement item is not medically 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a socket insert (L5655), Ottobock Trias foot (L5981, L5986).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve continuous intraoperative neurophysiology monitoring. We 
decided that the Plan does not have to pre-approve Orthofix Trinity Elite allograft.   

You asked the Plan to pre-approve Orthofix Trinity Elite allograft and continuous intraoperative 
neurophysiology monitoring (20930 and 95941). You say that the services are necessary. The Plan says that 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve continuous intraoperative neurophysiology monitoring.  
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury.  
 
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 continuous intraoperative 
neurophysiology monitoring. Our reviewer says that the services are medically necessary. Our physician 
reviewer found continuous neurophysiology monitoring in the form of somatosensory evoked potentials 
(SSEP) and/or maximal expiratory pressure (MEP) monitoring is the standard of care for surgery in the region 
of the spinal cord.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous intraoperative neurophysiology monitoring have been met. 
Therefore, we decided that the Plan has to pre-approve continuous intraoperative neurophysiology monitoring.  
 
We also decided that the Plan does not have to pre-approve Orthofix Trinity Elite allograft. 
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury.  
 
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 Orthofix Trinity Elite allograft. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found Trinity allograft is 
not medically needed. Iliac crest autograft or structural allograft is the gold standard.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthofix Trinity Elite allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Orthofix Trinity Elite allograft. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) with interpretation and report (80053, 82947, 84484, 85025, 93000, and 99285) billed to the enrollee for December 14, 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 upheld the Plans denial. Upon second review it was determined a more descriptive content was required for the letter to include all codes appealed.
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every HCPCS code. The billed procedure code,93000, has an OPPS status indicator of M, which means it is not billable for Medicare claims. As the procedure code itself cannot be paid as billed, all codes on the claim will be denied for payment as they are related to the procedure. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) with interpretation and report billed with code 93000 for December 14, 2021.
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 these OON services. You say that the enrollee has been seeing this provider 
since they were diagnosed and throughout cancer treatment. The Plan denied your request. The Plan says the 
requested services can be provided by a 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 27, 2022.
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 7, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 7, 2022.
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 enrollee is weak and requires therapy to 
strengthen their body. The Plan denied your request. The Plan says the services are 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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: 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 enrollee cannot leave the hospital without being 
admitted to rehab. The Plan denied your request. The Plan says the services the enrollee needs can be provided 
safely in another setting such as a skilled nursing facility. 
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered item or service, self-administered drugs 
(A9270) provided November 26, 2022, to November 28, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you went to the hospital for impaired 
speech, dizziness and shaking. The Plan denied your request. The Plan says this item is not covered.  

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the non-covered item or service, 
self-administered drugs (A9270) provided November 26, 2022, to November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87529, and 87581 billed for date of 
service April 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that complete medical records were provided. The 
Plan denied your request. The Plan says the billed codes do not meet coding criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87150, 87529, and 87581 are not payable when billed with multiple codes for the same 
intended use. 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 procedure codes 87150, 87529, 
and 87581 billed for date of service April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTAC admission 
criteria and the enrollee's needs cannot be met at a lower level of care. The Plan denied your request. The Plan 
says the LTACH is not medically necessary, and the enrollee's needs are being met at the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute respiratory failure in the setting of 
pneumonia. The record indicates that the enrollee has ongoing acute medical issues including altered mental 
status and still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.