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

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) provided on 
April 19, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and codes G0480 and 
80307 are not supported in the records provided. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures. The CPT Code Manual definition of code G0480 is drug test(s), 
definitive, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, the records provided do not include test 
results for any presumptive or screening drug tests. Without these results, we cannot verify the services were 
provided as billed. Code G0480 is not supported, as the records show that drugs from more than 7 classes were 
tested. There is a more appropriate code to report the services provided. In addition, we find that the testing 
described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for 
drug testing services (G0480, 80307 and 83789) provided on April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 31, 2023 to March 
7, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a NOA covers contiguous 30-day periods of care 
until the individuals is discharged from Medicare home health services. 
 
We looked at the file and Medicare rules. The through date, March 07, 2023, is billed as the 35th day from the 
from date billed, January 31, 2023 which should be the 29th day. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided on January 31, 2023 to March 7, 2023.
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.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF services were
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 stated that Maximus did not apply the
correct criteria. The Plan noted that the medical records show at the time of the appeal your ability to
participate in intensive therapy was described as limited by the hospital physical therapist, given your
dizziness and apprehension.

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, at the time of the appeal, it was not expected that you had the ability to
actively participate in and benefit from an intensive rehabilitation therapy program. Medicare rules for
coverage of IRF care were not met. Therefore, we decided that the Plan does not have to provide coverage for
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 it is medically necessary. The Plan denied your 
request. The Plan says you do not have complex rehabilitation needs. The Plan says services may be provided 
at a lower level of care.  
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status.  You can receive further 
services at a lower 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95913 and 2 units of procedure code 95886 
performed on date of service March 27, 2023. 
 
You asked the Plan to pay for 95913 and 2 units of 95886. You say that 95913 and 95886 should be paid as 
billed because they are supported in the medical record. The Plan denied your request. The Plan says 95913 
and 95886 are denied because they are not supported in 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 95913 is nerve conduction studies; 13 or more studies. 
The CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (list separately in addition to code for primary procedure). 
 
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 code 95913 and 2 units of code 95886. Our 
reviewer says that 95913 and 2 units of 95886 are not supported in the medical record. Our reviewer found 
there is no documentation that fully supports CPT codes 95913 and 95886 for date of service March 27, 2023. 
Provided records in this case include the interpretation of the nerve conduction study but do not contain the 
nerve conduction report of 13 or more studies as required for billing of CPT 95913. As the primary procedure, 
CPT 95913, is not supported, the add-on code of 95886 is also not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95913 and 2 units of code 95886 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95913 and 2 units of procedure code 95886 performed on date 
of service March 27, 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 enrollee has multiple complications that need to 
be monitored and needs rehabilitation in order to get stronger and become more independent. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare guidelines for medical necessity because the 
enrollee's medical condition requires further evaluation and treatment in the current acute care hospital.  
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 
There is not a reasonable expectation that this individual will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility.  There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain the enrollee's functional status.  The enrollee can 
receive further services at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight portable motorized/power wheelchair 
(K0012). 
 
You asked the Plan to pre-approve a lightweight portable motorized/power wheelchair. You say that you asked 
for the motorized scooter with the basket on the front of it. You also say that the one they gave you was too big, 
and it is sitting in your living room. The Plan denied your request. The Plan says based on the report from the 
expert, it was recommended the most appropriate mobility device for you is a group 2 four wheeled portable 
powered operated vehicle (scooter). The Plan also says the records show that the group 2 four wheeled portable 
powered operated vehicle (scooter) has already been approved under authorization number ending in 4174, and 
this request remains denied. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 lightweight portable motorized/power 
wheelchair. Our reviewer says that the lightweight portable power wheelchair (K0012) is not medically 
necessary. Our physician reviewer found there is limited documentation regarding your current level of 
function in terms of mobility and performing activities of daily living. There is also a lack of documentation 
regarding the specific graded motor strength and range of motion of your upper and lower extremities and your 
ability to safely use a lightweight, portable power wheelchair. Our reviewer also found that you were already 
approved for a group 2 portable power operated vehicle. 
 
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 lightweight portable motorized/power wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lightweight portable motorized/power 
wheelchair (K0012).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for chemotherapy services (J3490) provided on November 17, 2022.

You asked the Plan to pay for these services. 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 noted that
payment for these services is included in the payment for the chemotherapy administration or non-chemotherapy
injection and infusion services and cannot be billed separately.

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, based on the services provided and the Medicare billing guidelines, code
J3490 cannot be separately billed. Therefore, we decided the Plan does not have to pay for chemotherapy
services (J3490) provided to the enrollee on November 17, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from the 
LTACH services. The Plan denied your request. The Plan says that the LTACH services are 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee requires aggressive wound care, consultation from multiple physician specialties, 
daily labs, turning and repositioning every 2 hours, tight glucose control, and nutrition management. The 
enrollee currently does not require to be in a short-term acute care hospital. However, their needs cannot be met 
at a skilled nursing facility. The requested LTACH services are medically necessary, reasonable, and 
appropriate for them. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 18, 2023, to 
May 17, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
timely. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 18, 2023, to May 
17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85014, 85018) provided on March 24, 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 documentation does not support the codes 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. 
 
We find that CPT codes 85014 and 85018 are not supported in the medical record. Specifically, the Clinical 
Laboratory Improvement Amendments (CLIA) identifier in the records (18D1092600) does not match the 
CLIA identifier on the claim form (05D0580198). 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 (85014, 85018) provided on March 24, 2023.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 8 additional physical therapy visits. We decided that the Plan 
does not have to pre-approve 4 additional physical therapy visits.  
 
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that additional physical 
therapy visits are needed to gain stabilization and balance. The Plan says that additional physical therapy visits 
are not reasonable and necessary. 
 
We decided that the Plan has to pre-approve 8 additional physical therapy visits.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 additional physical therapy visits. Our 
reviewer says that 8 of the 12 requested visits are medically necessary. Our physician reviewer found you have 
received 7 sessions of physical therapy since June 22, 2023. The documentation indicates that you have made 
progress with therapy in terms of her strength, range of motion, and mobility. You continue to have functional 
deficits and would benefit from continued therapy for further gains and to transition to a home exercise 
program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have been met. Therefore, we decided that 
the Plan has to pre-approve 8 additional physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 4 additional physical therapy visits. Our 
reviewer says that 4 of the 12 requested visits are not medically necessary. Our physician reviewer found 8 
additional sessions should be appropriate, and you can be re-evaluated at that time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 9, 2023, to 
March 9, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim was billed incorrectly. 
 
The Plan follows Medicare rules. The rules say that for home health services must be billed with a correct Q 
code. 
 
We reviewed the file and the Medicare rules. We find that the claim was not billed with a required Q code. 
Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from February 
9, 2023, to March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 23, 2023. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 23, 2023.