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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 4, 2022, 
through May 5, 2022. 
 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) for an elective excision of a 
malignancy of the arm with biopsy without significant complication except for a short run of non-sustained 
ventricular tachycardia (NSVT), treated with an intravenous (IV) antiarrhythmic medication, but no 
defibrillation, cardioversion, or other more invasive procedures and was stable following treatment. Based on 
the provided documentation, it was not expected that the enrollee would require hospital services that would 
have likely crossed two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from May 4, 2022, through May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable continuous positive airway pressure (CPAP). 
 
You asked the Plan to pre-approve a portable CPAP. You say that you would like coverage of a portable CPAP 
machine because you are going on 3 vacations and did not want to have to carry the big machine around. The 
Plan denied your request. The Plan says Medicare does not pay separately or make an additional payment for 
backup equipment. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a continuous positive airway pressure that was provided April 2021. The current 
continuous positive airway pressure serves the same purpose as a portable CPAP. Therefore, we decided that 
the Plan does not have to pre-approve a portable continuous positive airway pressure (CPAP).
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 long term acute care hospital level of 
care is medically necessary. The Plan denied your request. The Plan says long term acute care hospital level of 
care is not medically necessary. 
 
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 in their current acute care setting as 
provided by the Health Plan. Documentation does not support that LTACH services are 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has Parkinson's disease and 
cancer and is not healthy enough to get chemotherapy. You say that the enrollee needs the LTACH in order to 
get better so he can continue treatment. The Plan denied your request. The Plan says the LTACH services are 
not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility, home with home health services, or outpatient setting. 
 
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 all expected and reasonable care at the acute care hospital. There are no specific treatments or services that would be offered at the LTACH. It does not appear that the 
enrollee meets the criteria for LTACH treatment. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 12, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that urine panels are only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue are a PCR panel 
testing. The standard of care for the evaluation of urine is urinalysis with urine culture and sensitivity. The PCR 
panel testing is considered excessive testing and not medically necessary. Based on this information, we 
decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99497 billed for date of service January 12, 2023. 
 
You asked the Plan to pay for code 99497. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code is not supported by the medical record. 
 
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 99497 is Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, code 99497 is a time-based 
code.  The medical records do not state the number of minutes spent on this service, and that is required to bill this code. This means that the total time spent on this service must be documented in the medical record. Based 
on this information, we decided that Medicare rules for coverage of code 99497 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 99497 billed for date of service January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary. The Plan
denied your request. The Plan says that it is not medically necessary to control the power tilt option through the
joystick.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection. Our Medical Director states that the documentation supports that the enrollee's upper limb function
is sufficient to control the power options using the switches included in the allowance of these power options.
Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an electronic
connection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided
that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 27, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you disagree with the denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 23 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on September 30,
2022.
You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary. The Plan
denied your request. The Plan says that the claim was billed with an inappropriate DEX Z-code. Maximus
overturned the Plan's denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code
Z00D5 coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that
confirms this.
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. In this case the reported
DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for
the genetic testing provided to the enrollee on September 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for applications of skin-substitute graft (15271, 15272) provided 
on October 13, 2022. 
 
You asked the Plan to pay for applications of skin-substitute graft. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of certain skin-substitute 
application procedures require the reporting of a skin-substitute product for the same day.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of applications of skin-substitute graft have not been met. Specifically, the request is for payment for 
high-cost skin-substitute procedures. A skin-substitute product has not been reported for the same date of 
service. Therefore, we decided that the Plan does not have to pay for applications of skin-substitute graft 
(15271, 15272) provided on October 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided February 1, 2022, through 
February 4, 2022. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the claim form does not have the appropriate home 
health data to process and pay the claim. The claim must have the appropriate type of bill to process. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of home health services have not been met. The claim was billed  
with an invalid type of bill. We find the Medicare rule for payment of this February 1, 2022, through February 
4, 2022, claim has not been met. Therefore, we decided that the Plan does not have to pay for home health 
services provided February 1, 2022, through February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiofrequency ablation (RFA) of the 
genicular nerves (64624 x2, 76942 x2). 
 
You asked the Plan to pre-approve ultrasound guided RFA of the genicular nerves. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 ultrasound guided RFA of the genicular 
nerves. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental/investigational 
procedure. It is the subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable and 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 ultrasound guided RFA of the genicular nerves have not been met. Therefore, 
we decided that the Plan does not have to pre-approve ultrasound guided radiofrequency ablation (RFA) of the 
genicular nerves (64624 x2, 76942 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services provided on April 30, 2023. 
 
You asked the Plan to pay for remote physiologic monitoring treatment management services. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the Plan has to pay for care 
from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved 
care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for remote physiologic monitoring treatment management services 
provided on April 30, 2023.
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 IRF care is medically necessary. The Plan 
denied your request. The Plan says  the IRF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as a skilled nursing facility, home with home health services, or home with 
outpatient therapy. 
 
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 non-surgical management of a hip fracture after a fall. 
The enrollee's 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 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. 
 
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 enrollee was sent to rehab to regain their 
strength after having a stroke. You say that the enrollee has had a set back after falling in the rehabilitation 
facility.  The Plan denied your request. The Plan says a SNF admission is not medically necessary.  
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 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 procedure code G0483 billed for date of service February 23, 
2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service billed. 
 
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 G0483 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, we did not find an order for 
testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0483 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0483 billed for date of service February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81120, 81121, 81170, 81191, 81192, 81193, 
81210, 81235, 81270, 81275, 81276, 81309, 81311, 81314, 81272, 81401, 81403, 81404, 81479) provided on 
March 16, 2023. 
 You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 lab services (81120, 81121, 81170, 
81191, 81192, 81193, 81210, 81235, 81270, 81275, 81276, 81309, 81311, 81314, 81272, 81401, 81403, 81404, 
81479) provided on March 16, 2023.