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

 
We decided that the Plan does not have to pay for drug testing provided on February 16, 2023. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the lab results do not support these codes. 
 
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. The CPT Code Manual definition of code 80307 is 
drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service. 
 
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 drug testing. Our reviewer says that this coding is not 
supported. Our reviewer found the medical record does not include a laboratory report with testing and results 
for this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing provided on February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640-59 and 87491-59 billed for date of 
service July 13, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says the billed codes are 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 87491-59 is infectious agent detection by nucleic acid 
(DNA or RNA); Chlamydia trachomatis, amplified probe technique. We find that CPT code 87491-59 is not 
supported in the medical record. The records do not show that this testing was ordered or provided.  
 
We have confirmed that code 87640 is a column II code to column I code 87641. The records do not show that 
code 87640, billed with a 59 modifier, was a separate and distinct test. Based on this information, we decided 
that Medicare rules for coverage of the billed testing have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87640-59 and 87491-59 billed for date of service July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code 99053 billed for date of service October 26,
2022.

You asked the Plan to pay for code 99053. The Plan denied your request. The Plan says the Medicare billing
criteria were not met.

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 have not been met.

Therefore, we decided that the Plan does not have to pay for procedure code 99053 billed for date of service
October 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 8, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from December 8, 2023, forward. You say that 
this is medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
December 8, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of December 8, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 8, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from December 8, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 8, 
2023, forward.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service June 5, 2023. 
 
You asked the Plan to pay for procedure code 95937. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this code is not supported in the medical 
record, as it was inappropriately used to report train-of-four testing. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 procedure code 95937. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found that the procedure report documents "TO4 [train-of-four]; 95937 - Neuromuscular Junction Test (TO4)". For CPT 95937, the provider performs neuromuscular 
junction testing by repetitive stimulation of a nerve supplying a muscle to diagnose a patient with a known or 
suspected disorder of the neuromuscular junction. It is not appropriate to bill separately for train-of-four (TOF) 
monitoring. The American Medical Association has clearly stated that CPT code 95937 is not appropriate for 
this procedure, nor may TOF monitoring be billed separately with an unlisted code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87634) provided on April 18, 2023. 
 
You asked the Plan to pay for the lab services denoted by code 87634. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services denoted by code 87634 have not been met. Specifically, this claim was billed with 
the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for lab services (87634) provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for code A4258 billed to the enrollee for November 20, 2022.

You asked the Plan to pay for code A4258. The Plan denied your request. The Plan says this code can only be
billed every six months. Maximus overturned the Plans denial for insufficient claim information in the case
file. The Plan requested a reopen and provided the required claim information. The claim information shows
this code was billed to the enrollee on June 13, 2022.

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 claims show this code was billed to the enrollee on June 13, 2022,
less than six months prior to the billed date of November 20, 2022, and making this claim ineligible for
payment. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan
does not have to pay for code A4258 billed to the enrollee for November 20, 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 this is medically necessary. The Plan denied your
request. The Plan says that the services you need can be provided safely in other settings, for example, a skilled
nursing facility. Maximus overturned the Plan's denial stating IRF care would be beneficial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. Whether or
not the care would be beneficial is not an appropriate review, the records clearly show that at the time of the
appeal prior to admission you did not meet all the criteria required by Medicare for coverage. 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 provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus did not apply the
correct criteria. The Plan noted that the medical records show the enrollee's ability to participate in therapy was
limited by the new below the knee left leg amputation, as well as weakness and fatigue.

The Plan is correct in this case. 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. Based
on the medical records provided, the enrollee was not expected to be able to participate in at least 3 hours a day
for 5 days a week of the type of therapy provided in an IRF. Therefore, we decided that the Plan does not have
to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 23, 2023, billed with 
procedure codes 95908-26-59 and 95885-26. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 95908-26-59 and 95885-26 is nerve conduction studies; 
3-4 studies, and needle electromyography, each extremity, with related paraspinal areas, when performed, done 
with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for 
primary procedure). 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that in this case, procedure code 95886 
cannot be verified, as nerve conduction studies are not documented in the medical record submitted for review. 
Code 95908 is not supported as there is a more specific code to report for documented 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 23, 2023, billed with procedure codes 
95908-26-59 and 95885-26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for the billed service. You say that the testing should be covered. The Plan denied 
your request. The Plan says the billed code is 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 0241U is infectious disease (viral respiratory tract 
infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], 
influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen 
reported as detected or not detected. 

We find that CPT code 0241U is not supported in the medical record. The documentation supports that this 
panel used the nucleic acid probe technique. There is a more applicable code available that describes the 
services provided. Based on this information, we decided that Medicare rules for coverage of the billed code 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U billed 
for date of service December 20, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care
for the enrollee beyond April 13, 2023.

You asked the Plan to provide coverage for continued SNF care. You say that at the time of the appeal,
continued care was medically necessary. The Plan denied your request. The Plan says the Medicare coverage
criteria for SNF admission were no longer met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the medical records show
the enrollee had received intensive therapy at an inpatient rehabilitation facility (IRF) followed by additional
daily skilled services in the SNF for a combined 32 days. The medical records show the enrollee's progress had
plateaued and any further care was custodial in nature.

The Plan is correct in this case. 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.
Based on the medical records provided, as of April 14, 2023, the enrollee no longer required daily skilled
therapy or daily skilled nursing services at an inpatient SNF level of care. Therefore, we decided that the Plan
does not have to provide coverage for continued skilled nursing facility (SNF) care for the enrollee beyond
April 13, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care
after April 13, 2023.

You asked the Plan to provide coverage for continued SNF care. You say that at the time of the appeal,
continued SNF admission was medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted
that Maximus did not apply the correct criteria. The Plan noted that you were admitted to the SNF on March
29, 2023, and showed little to know improvement since your admission. As of April 13, 2023, your care was
considered custodial which is not covered by Medicare.

The Plan is correct in this case. 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.
Based on the medical records provided, as of April 13, 2023, you no long required daily skilled nursing or daily
skilled therapy services at an inpatient level of care. Custodial care is not covered by Medicare. Therefore, we
decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care after
April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), harness (E2313), and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and an expandable controller. 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 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 an electronic connection, harness, and 
an expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has adequate strength to 
manage standard power drives. 
 
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, harness, and an expandable controller have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), harness (E2313), and an 
expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for PuraPly AM, per sq cm (Q4196), TheraSkin,
per sq cm (Q4121) and Apligraf, per sq cm (Q4101) for you.

You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal, this treatment
was medically necessary. The Plan denied your request. The Plan says the wound was healing and medical
necessity for three different types of application was not established. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
wound was improving with the local wound care (which Maximus agrees with).

The Plan also noted there is no documentation that you failed standard wound therapy (including failure or lack
of healing after treatment of the acute cellulitis on February 27, 2023, with the new course of antibiotics). The
Plan further notes the request is for three different products for a wound which is 5mm in its greatest
diameter/dimension (and only 8 mm in greatest dimension even after debridement).

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Medicare rules say that for Medicare to consider
coverage and payment for any item or service, the information submitted by the supplier or provider must
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage
criteria have been met. The medical records do not indicate you have failed traditional wound treatment. The
records also do not explain why three different types of skin substitute are required. Therefore, we decided that
the Plan does not have to provide coverage for PuraPly AM, per sq cm (Q4196), TheraSkin, per sq cm (Q4121)
and Apligraf, per sq cm (Q4101) for you.