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

 
We decided that the Plan does not have to pre-approve a parathyroid planar imaging with tomographic 
(SPECT) (78071). 
 
You asked the Plan to pre-approve a parathyroid planar imaging. You say that you disagree with the denial. 
The Plan denied your request. The Plan says a nuclear medicine parathyroid scan is medically necessary when 
there is hypercalcemia with an elevated parathyroid hormone level, and surgery is being planned. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a parathyroid planar imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee has a history of CKD and elevated 
Ca++ to 11. There are no results for PTH. His provider has requested a Parathyroid planar imaging (including 
subtraction, when performed); with tomographic (SPECT) (78071). Per Medscape Internal Medicine, the 
indications for a parathyroid MIBI scan are documentation of elevated serum calcium and parathyroid hormone 
and documented increased urinary excretion of calcium is also advised when other laboratory abnormalities are 
mild. History of prior thyroid or parathyroid surgery should be provided. The review has determined that the 
items/services at issue in this case are 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 a parathyroid planar imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a parathyroid planar imaging with tomographic (SPECT) (78071).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2330), and a prefabricated stainless-steel crown (D2931) provided on May 25, 2022.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the services provided are not covered under the dental benefit. Maximus partially overturned the Plans denial. The Plan requested a reopen provided documentation to show that this claim processed with a $61.00 payment to the provider. The Explanation of Benefits (EOB) shows the Plan $61.00 towards code D2330 on June 18, 2022. The EOB also show your liability of $212.00 due to benefit exclusions on code D2931 ($200) and D2330 ($12).
The Plan is correct in this case. 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 services provided are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for a filling (D2330), and a prefabricated stainless-steel crown (D2931) provided on May 25, 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 IRF services are necessary because the enrollee 
requires a comprehensive rehabilitation to monitor physical therapy and occupational therapy, disease 
processes, and medication management. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for elective knee replacement surgery. The enrollees medical problems are stable and 
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 enrollee may have a need for physical therapy 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour brand diabetic testing supplies. 
 
You asked the Plan to pre-approve Contour supplies. You say that the enrollee has diabetes and tests twice 
daily. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Contour supplies. Therefore, we decided that the Plan does not have to pre-approve Contour brand diabetic 
testing supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional hours of the in-home support benefit. 
 
 
You asked the Plan to pay for the additional hours. You say that  The Plan denied your request. The Plan says 
additional hours cannot be covered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all contract information. 
 
The plan only covers 60 hours of these services per year. Once you have hit 60 years, the benefit is exhausted. 
Therefore, we decided that the Plan does not have to pay for additional hours of the in-home support benefit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiopharmaceutical localization of tumor, 
inflammatory process, or distribution of radiopharmaceutical agent(s); tomographic (SPECT) with concurrently 
acquired computed tomography (CT) transmission scan for anatomical review, localization and 
determination/detection of pathology, single area, single day imaging (78830). 
 
You asked the Plan to pre-approve a nuclear medicine test. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a nuclear medicine test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have invasive lobular carcinoma. The surgical plan for the known invasive 
lobular carcinoma is lumpectomy and sentinel node biopsy. There is no explained indication for SPECT CT.  
Most likely the intended order is for sentinel node lymphoscintigraphy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a nuclear medicine test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a radiopharmaceutical localization of tumor, inflammatory process, or distribution 
of radiopharmaceutical agent(s); tomographic (SPECT) with concurrently acquired computed tomography (CT) 
transmission scan for anatomical review, localization and determination/detection of pathology, single area, 
single day imaging (78830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Flexabed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is unclear why a covered bed with similar functionality would not meet medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bed. Our reviewer says that the 
requested bed is not considered medically reasonable and necessary in this case. Our physician reviewer found 
a review of the requested item online indicating that it is a luxury alternative to a hospital bed for the home. 
The documentation does not reveal extenuating factors that require this luxury bed with massage features for 
this patient's conditions. The requested item exceeds her medical needs.  
 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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Flexabed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided from June 9, 2022, to June 10, 2022, under the Medicare benefit.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says These services are covered under your Medicaid benefit.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan says this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers. These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided from June 9, 2022, to June 10, 2022, under your Medicare benefit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided to the enrollee from April 1, 2022, to April 6, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan submitted documentation to show an approved authorization exits, but the number of visits billed do not match what was approved on the authorization. The approved authorization was for January 22, 2022. The appealed date of service is for April 1, 2022, to April 6, 2022. A new authorization would have been required for this request.
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 the records show no authorization for these dates of service.
The Plan notes a correct claim would be reviewed if submitted. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services provided to the enrollee from April 1, 2022, to April 6, 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. The enrollee may benefit from physical and 
occupational therapy but does not need the intensity of these therapies provided in the acute inpatient 
rehabilitation 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 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 you disagree with the denial. 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 was readmitted to the hospital for respiratory failure after complications 
from a right neck dissection. He has active medical comorbidities; however, the complexity of his nursing, 
medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The IRF services are 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on September 21, 2022. 
 
You asked the Plan to pay for the services. You say that there is sufficient documentation in the record that 
supports the patient's initial findings were consistent with a broad range of high risk diagnoses requiring 
medical decision making of high complexity, a comprehensive history, and comprehensive examination. The 
Plan denied your request. The Plan says the original billed code is not supported by the medical documentation 
submitted. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function." 
 
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 documentation does 
not note medical decision making of high complexity.  Therefore, the billing of CPT 99285 is not supported. 
 
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 emergency department services (procedure code 99285) rendered on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code 99284 provided to the enrollee on June 11, 2022.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that a review of both claims shows both billing physicians are part of the same group with the same NPI specialty. 
While this service is unrelated based on the diagnosis codes, and was performed by different physicians, both physicians have the same specialties and are part of the same group, which allows them to be considered the "same" physician. Per Medicare Claims Processing Manual, Chapter 12, Section 40.1B, Services Not Included in the Global Package: A/B MACs (B) do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field 16 of the MFSDB. These services may be paid for separately.
Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.
Per Medicare Claims Processing Manual, Chapter 12, Section 40.2A7 - Unrelated Procedures or Visits
During the Postoperative Period: Modifier "-24": Reports an unrelated evaluation and management service by same physician during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during the postoperative period of an unrelated procedure. This circumstance is reported by adding the modifier "-24" to the appropriate level of evaluation and management service. Per the above Medicare guidelines, the Plan has correctly denied the claim for payment as 99284 was not billed with a 24 modifier.

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 code and when necessary, the appropriate modifier. In this case this claim could not be paid as billed due to the omission of the required 24 modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 provided to the enrollee on June 11, 2022.