Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an Epidural Steroid Injection (ESI) (62321 x1). 
 
You asked the Plan to pre-approve an Epidural Steroid Injection. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. 
 
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 Epidural Steroid Injection. Our 
reviewer says that the requested service is medically necessary. Our physician reviewer found that it is standard 
of care to perform the ESI at either C6-C7 or C7-T1 because of the anatomic changes that occur at higher 
levels. This request is entirely appropriate and is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Epidural Steroid Injection have been met. Therefore, we decided that the 
Plan has to pre-approve an Epidural Steroid Injection (ESI) (62321 x1).  
 
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: Favorable

 
We decided that the Plan has to pay for procedure codes 80307 and 83789 provided on December 21, 2022. 
 
You asked the Plan to pay for procedure codes 80307 and 83789. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The rules also 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 follows these rules. 
 
The enrollee was referred for procedure codes 80307 and 83789 by a contract provider. The file does not show 
that the plan provided notice that procedure codes 80307 and 83789 would not be covered. Under Medicare 
rules, this means procedure codes 80307 and 83789 is considered approved by the plan.  
 
Additionally, 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 denied payment for code 80307 due to a 
different provider submitting a claim for a presumptive test on the same date of service; however, the Plan 
provided no claim of payment for the other testing submitted. Therefore, we decided that the Plan has to pay 
for procedure codes 80307 and 83789 provided on December 21, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services provided on November 3, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the authorization was issued with the primary 
diagnosis code. The Plan denied your request. The Plan says there is a more appropriate diagnosis available. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that the claim was billed with diagnosis codes M16.11, unilateral primary osteoarthritis of the right 
hip, and M16.12, unilateral primary osteoarthritis of the left hip. There is a more appropriate code to indicate a 
condition is bilateral. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the occupational 
therapy services provided on November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel testing provided on December 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that documentation was provided. The Plan denied 
your request. The Plan says the documentation does not support separate services. 
 
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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the respiratory panel testing provided on December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761, and 99072 billed for date of 
service October 5, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported for code 87631. Based on this information, we decided that Medicare rules for coverage 
have not been met. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. Procedure code 
94761 has a status indicator of T. In this case, the procedure codes are not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87631, 94761, and 99072 billed for date of 
service October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 20, 2021, 
through November 24, 2021, and billed with diagnosis code A41.51. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.51 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.51. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.51-Sepsis due to 
Escherichia coli. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the primary 
diagnosis of A41.51. Our physician reviewer found The member presented with weakness and anorexia.  The 
member was found to have a urinary tract infection (UTI) and dehydration. The initial laboratory abnormalities 
responded well to simple hydration. There is no evidence of organ failure. The billing of A41.51 is not 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 20, 2021, through November 24, 2021, and billed with 
diagnosis code A41.51.
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 you need rehab to grow stronger in order to 
discharge to home safely. The Plan denied your request. The Plan says that IRF care is not considered 
medically reasonable and 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 complexity of your documented nursing, medical, and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Clinical documentation shows that you require ongoing physical and occupational therapy 
however, inpatient therapy goals have been met and you would not be expected to require an intensive 
rehabilitation regimen. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple instances of ambulance transportation (A0427, 
A0425) billed for date of service October 4, 2022. 
 
You asked the Plan to pre-approve ambulance transport. You say that the enrollee was provided with two 
separate ambulance transports on the same day. The Plan denied your request. The Plan says the documentation 
provided does not support multiple transports on the date in question. 
 
The Plan must follow Medicare rules. 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ambulance transport have been met. 
Specifically, the medical records provided only detail one transport where the enrollee was transferred from the 
ambulance to the hospital around 11:30am.. Therefore, we decided that the Plan does not have to pre-approve 
multiple instances of ambulance transportation (A0427, A0425) billed for date of service October 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says your condition does not meet Medicare guidelines for 
admission to a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Glatiramer Acetate. 
 
You asked the Plan to pre-approve the medication. You say that the drug should be covered. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Glatiramer Acetate.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on November 15, 2022. 
We also decided that the Plan does not have to waive the copayment for the cardiac stress test provided on 
November 15, 2022.  You asked the Plan to waive the cost share for the cardiac stress test and drug injection. You say that you were 
not told ahead of time about these costs. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the drug injection provided on November 15, 
2022.  
 
You have been asked to pay 20% coinsurance for the drug injection. According to Medicare, the injection 
(code J2785) is considered a packaged code and is not separately payable. This code is also excluded from the 
physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the drug 
injection provided on November 15, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the cardiac stress test provided 
on November 15, 2022. 
 
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 $75 
copayment for nuclear medicine, including a cardiac stress test.  
 
You have been asked to pay $75 copayment for the cardiac stress test. This item/service falls within the 
outpatient diagnostic tests and therapeutic services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. 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 share for the cardiac stress test. 
 
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 a partial colectomy with coloproctostomy (44145) and 
associated inpatient admission. 
 
You asked the Plan to pre-approve a partial colectomy with coloproctostomy and associated inpatient 
admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 a partial colectomy with 
coloproctostomy and associated inpatient admission. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found in this 
case, there is not any evidence of acute diverticulitis. Further, there is no radiographic or clinical evidence of 
bowel perforation, or any other complications related to diverticular disease at this 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 a partial colectomy with coloproctostomy and associated inpatient admission 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial colectomy with 
coloproctostomy (44145) and associated inpatient admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from July 4, 2020, to July 14, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. 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 provided additional information.
The Plan noted that the claim for this 30-day payment period contained 3 billed visits include Physical Therapy dated July 6, 2020, July 9, 2020, and July 14, 2020. The "LUPA" visit threshold for this 30-day payment period HIPPS code billed 3LB21 is 2. Physical Therapy visits billed July 6, 2020, and July 9, 2020, are nonbillable due to a valid reassessment not being completed timely. Therefore, the claim was repriced correctly to reflect the one billable Physical Therapy visit billed July 14, 2020. The appropriate payment for the claim is LUPA Physical Therapy X1 per visit payment rate according to the calendar year 2020 rate table
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, this claim could not be paid as billed due to an error with the visits billed within the 30-day payment period. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from July 4, 2020, to July 14, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy with biopsy (45380). 
 
You asked the Plan to pre-approve a colonoscopy with biopsy. You say that this is medically necessary. The 
Plan denied your request. The Plan says that you are not due for a colonoscopy until 2024. 
 
The Plan follows Medicare rules. Medicare rules say that a diagnostic colonoscopy is indicated for evaluation 
of the entire colon for a cancer with polyps noted on an earlier colonoscopy in accordance with the established 
national guidelines. 
 
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 colonoscopy with biopsy. Our 
reviewer says that you meet the criteria for coverage. Our physician reviewer found that your personal history 
and family history meet the definition of high risk for colorectal cancer, and the timeframe as requested is a 
covered benefit. 
 
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 colonoscopy with biopsy have been met. Therefore, we decided that the Plan 
has to pre-approve a colonoscopy with biopsy (45380).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the personal trainer services (S9451) 
purchased on January 1, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
  
 
 
The Plans rules for coverage of gym benefits have not been met because the services purchased in this case are 
not covered under the wellness allowance benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the personal trainer services (S9451) purchased on January 1, 2022.