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

 
We decided that the Plan does not have to pay for long-term electroencephalographic (EEG) monitoring 
provided from July 5, 2022 to July 10, 2022. 
 
You asked the Plan to pay for long-term EEG monitoring. You say that the long-term EEG monitoring was 
medically necessary. The Plan denied your request. The Plan says long-term EEG monitoring is experimental. 
 
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 pay for long-term EEG monitoring. Our reviewer 
says that long-term EEG monitoring is not considered medically reasonable and necessary. Our physician 
reviewer found that EEG video monitoring is considered experimental and investigational for all other indications (e.g., assessment of obstructive sleep apnea, amyotrophic lateral sclerosis (ALS), cardiac arrest, 
chronic fatigue, coma, headache, and assessment of the effectiveness of drug treatment in epilepsies, diagnosis 
of brain death, and prognosis of cardiac arrest treated with hypothermia, and newborns with hypoxic-ischemic 
encephalopathy treated with hypothermia; not an all-inclusive list) because its effectiveness for these 
indications has not been established. In this case, the enrollee is having issues (headache, imbalance, confusion, 
dizziness) related to a magnetic resonance imaging identified right hemisphere multifocal mass concerning for 
a high-grade glioma. The review has determined that long-term EEG monitoring at issue 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 long-term EEG monitoring have not been met. Therefore, we decided that the 
Plan does not have to pay for long-term electroencephalographic (EEG) monitoring (CPT 95720) provided 
from July 5, 2022 to July 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code S9122. 
 
You asked the Plan to pre-approve procedure code S9122. The Plan denied your request. The Plan says the 
requested code is invalid for Medicare purposes. 
 
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 S9122 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9122 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9122 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code S9122.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 74176 is bundled into payment for code 74177. 
 
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 74176 
is a column II code to column I code 74177. 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 procedure code 74176 billed for date of service June 21, 2022.
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 you won't get to your baseline at a 
skilled nursing facility. You say you need to go to the LTACH to get the exact care you need. The Plan denied 
your request. The Plan says based on Medicare guidelines, the LTACH services requested do not meet the 
requirements for approval. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The Plan has approved ongoing care in the current acute care 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided to the 
enrollee on March 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99239 (1 Units) remains 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 99239 is "Hospital discharge day management of more 
than 30 minutes." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records do not 
sufficiently support that more than 30 minutes of discharge day management was rendered on this date of 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital discharge day management services provided to the enrollee on March 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of overactive 
bladder. He has not tried and failed the Plan's required drugs, one urinary anticholinergic drug and Myrbetriq. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Botox is 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) (37215). 
 
You asked the Plan to pre-approve PTA. 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 follows Medicare rules. Medicare rules say that PTA is covered under certain circumstances. 
 
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 PTA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has >70% stenosis of the left 
internal carotid but is not symptomatic and there is no documentation of why the enrollee would not be a 
candidate for left carotid endarterectomy. Stenting and PTA is currently covered for enrollees who are not 
surgical candidates or are at high risk of stroke. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous transluminal angioplasty (PTA) (37215).
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 the enrollee was admitted for surgical management of patellar fracture and humerus 
fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that the 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs billed with code J3490 for September 
19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intra-operative services that are normally a usual and 
necessary part of a surgical procedure are included in the global surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed for the same date of 
service as minor surgical procedure 27096. Payment for code J3490 is included in the global surgical package. 
Therefore, we decided that the Plan does not have to pay for the unclassified drugs billed with code J3490 for 
September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure, (81479) provided 
January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the decision to deny the 
claim on the basis of requiring prior authorization or advanced notification. The Plan denied your request. The 
Plan says the service does not meet Medicare LCD L35000 criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. medical records were needed to establish how the results of the lab test has impacted the enrollees treatment. 
The records show the Plan made multiple attempts to obtain medical records from the enrollee without success 
Therefore, we decided that the Plan does not have to pay for unlisted molecular pathology procedure, (81479) 
provided January 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 21, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says a mental health 
counselor is not eligible to bill Medicare for mental health services. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on July 21, 2022.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria 
for admission to an IRF 
 
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 patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 18, 2021 and billed under claim A with code 99221.
You asked the Plan to pay this claim. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The noted claim A denied because the Plan already paid for this service under claim B.
There is no information in the medical records to support why this procedure would have been rendered twice on the same day. The NPI website shows the billing provider for claim A practices in Internal Medicine and Nephrology Specialists. The case file includes the claim image for the appealed and referring claims that show that both providers belong to the same physician group. The correct billing of this service needed to include modifier 59, which is used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury. The modifier was not billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, claim A cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 18, 2021, and billed under claim A with code 99221.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 10, 2022.
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. The Plan requested a reopen and provided additional information. The Plan notes that the date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected with 3 exceptions. Maximus referenced the chemotherapy sensitivity test/service performed on live tissue exception. The Medicare rule state in the case of a chemotherapy sensitivity test/service performed on live tissue, the date of service of the test/service must be the date the test/service was performed only if: - The decision as to the specific chemotherapy agent to test is made at least 14 days after discharge; - The specimen was collected while the patient was undergoing a hospital surgical procedure; - It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted; - The results of the test/service do not guide treatment provided during the hospital stay; and - The test/service was reasonable and medically necessary for treatment of an illness.
For purposes of applying the above exception, a "chemotherapy sensitivity test" is defined as a test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents. This claim does not meet the chemotherapy sensitivity test exception. The specimen was collected on March 30, 2022, and it was received by the laboratory on March 31, 2022. Therefore, the test was not ordered at least 14 days after discharge. This also test does not meet the definition of chemotherapy sensitivity test. The claim was billed with a place of service (POS) code of 81, Independent Laboratory, independent of an institution or a physician's office, however the records clearly show the sample was not taken by the independent laboratory.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid due to the omission of a correct POS code and the fact that the enrollee did not meet the required Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 10, 2022.