Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 77067 and 77063. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 76641.  
 
You asked the Plan to pay for testing services provided on December 27, 2022, billed with codes 76641, 
77067, and 77063. You say that the claim is billed correctly and should be paid. The Plan says that the units 
billed exceeds the maximum allowable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 77067 and 77063.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 77067 and 77063.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
76641. 
 
The Plan follows Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds 
the MUE value for the HCPCS/CPT code will be denied. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 76641 have not been met. In this case, the MUE for 
CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 
Specifically, you billed one line item of this code with the LT modifier and one line item of this code with the 
RT modifier instead of billing one line item with the bilateral modifier as is required. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 76641. 
 
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee is experiencing significant decline, is not able to discharge without proper physical therapy. The Plan denied your request. The Plan says that based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for approval. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not support that there was a reasonable expectation that this enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that he 
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 rehabilitation services 15 hours a week, 
under the supervision of a physician with at least three visits weekly to regain or maintain his 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 5, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that CardioMEMS is medically necessary for this 
patient. The Plan denied your request. The Plan says although CardioMEMS is approved by the Food and Drug 
Administration (FDA), this is not considered the standard of care at this time and shouldn't be approved outside 
of a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the CardioMEMS device is still not proven to be of significant improvement by any 
Randomized Clinical Trials (CRT) and still not recommended by the professional societies guidelines for Heart failure management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87556, 87640, 87798) provided on 
August 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were 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 panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (87481, 87556, 87640, 87798) 
provided on August 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services and infrared therapy provided on December 21, 2021, and December 23, 2021.
You asked the Plan to pay for the acupuncture services and infrared therapy. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that these services are not a covered benefit. Maximus overturned the Plan's denial. The Plan requested a reopening and stated we did not apply the correct criteria.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. The rules also state that infrared therapy is not a covered Medicare benefit. In this case this claim cannot be paid as billed as acupuncture is not covered for a diagnosis of low back pain, unspecified (M54.50) and infrared therapy is not a covered Medicare benefit. Therefore, we decided that the Plan does not have to pay for the acupuncture services and infrared therapy provided on December 21, 2021, and December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0862) and related 
accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says that the 
requested items are not medically necessary. 
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
has a neurologic disorder with functional deficits. The documentation does not indicate that the enrollee has 
any pressure injuries or requires intermittent catheterization of the bladder or has spasticity that would 
necessitate power tilt or recline. Although the enrollees condition may meet criteria for a PWC, the criteria for 
this specifically requested PWC with multiple power options including power tilt and recline are not met. As 
the PWC base is not medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0862) and related accessories.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a periodic comprehensive preventive medicine exam provided on 
December 28, 2022. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine. You say that your insurance 
covers your annual pap smear. The Plan denied your request. The Plan says that code 99397 is not a Medicare 
covered code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule to substantiate their 
denial. Therefore, we decided that the Plan has to pay for a periodic comprehensive preventive medicine exam 
provided on December 28, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator (L8679). 
 
You asked the Plan to pre-approve the nerve stimulator. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the requested item is non-covered. 
 The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation 
of auricular acupuncture points are non-covered. 
 
We looked at the file and Medicare rules. The requested device is an electro-acupuncture device and not a 
neurostimulator that is implanted in an operating room. Based on this information, we decided that Medicare 
rules for coverage of the nerve stimulator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a nerve stimulator (L8679).
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 is stable and ready to 
transfer to an LTACH for continuation of treatment. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the incision and drainage of hematoma, seroma or fluid collection (10140), the hospital outpatient clinic visit (G0463), debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or less (11042), selective debridement of the first 20 sq. cm of wound surface area (97597), application of multilayer compression system, leg (below knee), including ankle and foot (29581) provided from May 3, 2022 to June 7, 2022.
You asked the Plan to waive the cost-sharing for the incision and drainage of hematoma, seroma or fluid collection, the hospital outpatient clinic visit, debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or less, selective debridement of the first 20 sq. cm of wound surface area, application of multilayer compression system, leg (below knee), including ankle and foot. You say that you are being charged two copays for these services. The Plan denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copay for certain wound care services and a $300 copay for all other services in an outpatient hospital. The Evidence of Coverage also says that some clinics where you see providers may be owned by a hospital. When you receive services at these clinics you may have higher out-of-pocket costs because hospital-owned clinics may bill you for both the provider you see, and for the use of the facility the provider is in. Based on the claim and the codes submitted by your provider, and your Plan contract agreement, you have been charged the appropriate copayment for the services provided. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for the incision and drainage of hematoma, seroma or fluid collection (10140), the hospital outpatient clinic visit (G0463), debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or less (11042), selective debridement of the first 20 sq. cm of wound surface area (97597), application of multilayer compression system, leg (below knee), including ankle and foot (29581) provided from May 3, 2022 to June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hematolymphoid neoplasm gene panel testing of 51 genes for the enrollee.
You asked the Plan to pre-approve these services. You say that the testing is needed to aid the best treatment option for bicytopenia. The Plan denied your request. The Plan says that the testing is not FDA approved.
Our Medical director looked at the case file and the reopen request. At issue is coverage of hematolymphoid neoplasm gene panel testing of 51 genes. Our Medical Director states that the documentation does not support that the diagnostic laboratory test using NGS has FDA-approval or FDA-clearance as a companion in vitro diagnostic, and an FDA-approved or FDA-cleared indication for use in this enrollee's cancer, and that the results provided to the treating physician would be for management of the patient using a report template to specify treatment options. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve hematolymphoid neoplasm gene panel testing of 51 genes for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service December 
19, 2022. 
 You asked the Plan to pay for procedure code 11720. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 11720 is bundled into payment for code 11719. 
 
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 11720 
is a column II code to column I code 11719. 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 11720 billed for date of service December 19, 
2022.