Persius/hicric huggingface dataset:
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 is ready for the more extensive rehab 
that they would receive from Inpatient Rehab. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval.  
 
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 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 lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Syfovre (pegcetacoplan). 
 
You asked the Plan to pre-approve Syfovre (pegcetacoplan). You say that are requesting an extension per the 
submitted documents. The Plan denied your request. The Plan says that the request for Syfovre (pegcetacoplan) 
does not meet the Plan's clinical coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Syfovre (pegcetacoplan). Our reviewer 
says that the enrollee meets the criteria for Syfovre (pegcetacoplan). Our physician reviewer found that Syfovre 
is Food and Drug Administration approved for the enrollees diagnosis. The request use of Syfovre is supported 
by the Medicare-approved drug compendia. Our physician reviewer also found that the documentation supports 
that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Syfovre (pegcetacoplan) have not been met. Therefore, we decided that the Plan 
has to pre-approve Syfovre (pegcetacoplan).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, of 8-14 drug classes (G0481) 
provided July 10, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that this is an incorrect denial. This is just a urine 
drug scree service, and you are getting payment for this service.  The Plan denied your request. The Plan says 
the benefit for this service is included in the payment/allowance for another service/procedure that has already 
been adjudicated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code G0481 is a column II code to column I code 80307. This claim has 
not been billed with an appropriate modifier to bypass the edit. 
 
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 laboratory service. Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
provider reported procedure code without appended modifier with CPT 80307, which an NCCI Edit exists, 
however the laboratory report does not include documentation to support separate service, and a modifier was 
not appended to verify rationale for separate payment. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing, of 8-14 drug classes (G0481) provided July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barret's Esophagus test (0108U) provided 
on August 15, 2023. 
 
You asked the Plan to pay for the TissueCypher Barret's Esophagus test. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this test remains unproven for determining 
the risk of progression from Barrett's esophagus to high grade dysplasia or cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the TissueCypher Barret's Esophagus test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that TissueCypher testing is not standard of care and not 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 TissueCypher Barret's Esophagus test have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barret's Esophagus test (0108U) provided on 
August 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 30, 
2023. 
 You asked the Plan to pay for procedure code 99291. The Plan denied your request. The Plan says payment for 
code 99291 is bundled into payment for code 36620. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99291 
is a column II code to column I code 36620. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 5, 2023, billed with 
evaluation and management code 99223. 
 
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 code. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 We asked our physician 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 code. Our reviewer found that the documentation did not include an 
appropriate history or physical, did not support a high level of medical decision making, and did not note a 
duration of 75+ minutes to help support the code, 99223. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 5, 2023, billed with evaluation and 
management code 99223.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure code 87801) rendered on April 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that there are not any multiple organisms listed in the results. 
 
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 87801 is "Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique." 
 
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 supported by the medical records. Our reviewer found that the documentation supports that the 
referenced testing was performed, and that multiple organisms were tested for. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services (procedure code 87801) rendered on April 27, 2023.  
 
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: 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 needs this care before returning home. 
The Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, 
the enrollee needs can be safely provided at another setting.  
 
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 enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional home health skilled nursing visits for
the enrollee.

You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for five (5) additional
home health skilled nursing visits. Our Medical Director states that the enrollee had a pressure wound on the
plantar aspect of his right foot where a skin cancer was removed. The enrollee was approved for a total of 159
home health skilled nursing care visits from January 2023 to December 2023. The Encounter Summary dated
July 28, 2023, documents that the enrollee had a two centimeter round wound on the plantar aspect of his right
foot. The enrollee was instructed to elevate his legs, take medications as prescribed, drink plenty of water, add
protein to his diet, drink Boost and Ensure, and contact the Emcara team if there were new symptoms or a
change in his condition. The documentation does not show that five additional home health skilled nursing
visits were required to effectively provide treatment, care, and/or services in order to improve the enrollee's
condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent
deterioration. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of
home health services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve five (5) additional home health skilled nursing visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services and Pharmacogenomics Testing provided on
January 11, 2023.

You asked the Plan to pay for this testing. You say that you do not believe you should have to pay for this
testing. The Plan denied your request. The Plan says the medical records provided do not give a specific drug
treatment plan that supports the coverage of pharmacogenomic testing. Maximus overturned the Plan's denial
for insufficient records in the case file.

The Plan requested a reopen and noted it agrees with Maximus that the medical records are incomplete. The
Plan noted that Medicare states that pharmacogenomics testing (PGx) represented by code 81227 is indicated
when specific medications are being considered for use (or already being administered) that are medically
necessary, appropriate, and approved for use in the enrollee's condition and are known to have a gene(s)-drug
interaction that has been demonstrated to be clinically actionable. For this testing to be covered, medical
records must clearly reflect a diagnosis for which pharmacologic therapy is reasonable and necessary, and the
drug or drugs that the clinician is considering using must be reasonable and necessary for the treatment of the
enrollee's diagnosis. There is no available information to show this testing was part of a physician's decisionmaking
process regarding safely administering or dosing the drugs in this case. There is no physician statement
of an initial personalized decision or discussion of your diagnosis, your medical conditions, other medications
being taken, basic science pertinent to the drug (e.g., mechanism of action, side effects), past medical history
and when pertinent family history and the preferences and values.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. The medical records provided do not support
this service was medically necessary to form a treatment plan as opposed to being a screening as the medical
records do not contain a specific drug treatment plan established prior to the testing. Therefore, we decided that
the Plan does not have to pay for lab services and Pharmacogenomics Testing provided on January 11, 2023.
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 needs this care to regain 
function. The Plan denied your request. The Plan says medical records do not support the need for an LTACH 
admission and, the enrollee's needs can be managed at the current facility. 
 
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's care can be safely provided at the current facility until they are more 
stable and appropriate for transfer to another level of care. Completion of treatment at the current facility is 
recommended.  
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on the available information, 
admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 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 chest pain after a fall and alcohol withdrawal. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied CGM and that the services requested are medically necessary. The Plan 
denied your request. The Plan says that the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a continuous glucose monitor (CGM). 
Our reviewer says that the service is medically necessary. Our physician reviewer found as the enrollee is being 
treated with insulin, the coverage criteria are met; is at risk for hypoglycemia and is a good candidate for a 
CGM. 
 
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 continuous glucose monitor (CGM) have been met. Therefore, we decided 
that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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.