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 requires rehab nursing, physical therapy, 
occupational therapy, case management, and physician oversight. The Plan denied your request. The Plan says 
that the IRF services requested 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 29, 2022.  

You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, 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 validity testing billed with 
code 83789 for date(s) of service November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac catheterization provided on July 
14, 2022. 
 
You asked the Plan to waive the copayment for the cardiac catheterization. You say that you do not understand 
how you were charged this amount and were not told about the charges ahead of time. 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 $195 
copayment for surgical services provided at an outpatient hospital.  
 
You have been asked to pay a $195 copayment for the cardiac catheterization. This item/service falls within the 
outpatient hospital 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 copayment for the cardiac 
catheterization provided on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for services billed to the enrollee for July 7, 2022, and billed under code 84439.
You asked the Plan to pay for this claim. 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 stated that there were two claims submitted for code 84439. Each claim billed one unit. Per the Medicare guidelines, the Plan has correctly denied the second claim for payment. The coding guidelines show code 84439 has a Medically Unlikely Edit (MUE) value of 1, however 2 units were billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim in question could not be paid as billed due to the MUE value for code 84439. Therefore, we decided that the Plan does not have to pay for services billed to the enrollee for July 7, 2022, and billed under code 84439.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided to the enrollee on May 19, 2022, and billed under code 99213.
You asked the Plan to pay this claim. You say that this service should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating the service was billing correctly. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that the statement "This office visit was provided 2 days prior to procedure code 28805" was incorrect. The right foot amputation procedure 28805 occurred on April 21, 2022, and the office visit (99213) for wound care occurred on May 19, 2022, which is within the 90-day global period. This means code 99213 was denied because this service is included in the payment/allowance for another procedure that has already been reviewed. Both claims were billed with the same primary diagnosis code of M86.171 for "Other acute osteomyelitis, right ankle and foot". The medical record shows the office visit was for wound care related to the right foot amputation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case this claim could not be paid as billed due to its relation to the primary procedure and the diagnosis code billed.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 19, 2022 and billed under code 99213.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that the documentation shows medical necessity. 
The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 is a column II code to column I code 0089U. CPT code 81345 
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 
81345 billed for date of service November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) shows foraminal stenosis. The cause of the enrollee's back pain is not clear. The Intracept procedure is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Supartz FX (J7321). 
 You asked the Plan to pre-approve Supartz FX. You say that Supartz FX is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Supartz FX have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz FX. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Synvisc/Synvisc One or Euflexxa before they will approve the requested drug. The 
requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Supartz FX (J7321).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you had surgery in your right shoulder 
and needs additional therapy to help regain your strength and mobility. The Plan denied your request. The Plan 
says 8 additional physical therapy visits are not medically necessary 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you are receiving repetitive exercises during therapy 
and has an effective home exercise program. Therefore, continued input from a skilled therapist is 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99283) provided to the enrollee on July 1, 2022.
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 stated that Maximus did not apply the correct billing criteria. The Plan noted that Procedure code 99283 (Emergency department visit for the evaluation and management of a patient) was denied as "Incorrect Place of Service Billed". Per Medicare guidelines emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention.
Per the "Place of Service Codes for Professional Claims" list located the CMS.gov website, Place of Service 49 = Independent Clinic: A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. Per the Medicare guidelines, the Plan has correctly denied the claim for payment as emergency services were billed in place of service 49, which is not an emergency department setting.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate POS code. In this case, this claim could not be paid as billed due to the submission of an incorrect POS code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99283) provided to the enrollee on July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381 
billed for date of service March 17, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these 
codes are included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88365, and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88365, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 88341, 88342, 88360, 88365, and 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381 billed 
for date of service March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 18, 2022 and billed under code 99212.
You asked the Plan to pay for this service. 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 stating the records provided support the services billed. The Plan requested a reopen and stated that the issue was not medical necessity but the fact that the claim was billed without a required modifier. The Plan stated that to not have this service included in the global surgery package paid to the facility, the provider should have billed code 99212 with a 24 modifier in addition to the 25 modifier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code and when necessary, the appropriate modifier. In this case, this claim could not be paid as billed due to the omission of a required modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 18, 2022 and billed under code 99212.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total uterine removal (hysterectomy) and removal of 
both ovaries (salpingo-oophorectomy). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you reported a 
three-month history of heavy menstrual periods. A uterine ultrasound showed no fibroids. The records do not 
document that you have tried and failed appropriate alternative non-surgical treatment regimens prior to 
surgery. The requested procedures are therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total uterine removal (hysterectomy) and removal of both ovaries (salpingo-
oophorectomy).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services billed with code 64450 for date of 
service October 7, 2022. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services billed with code 64450 must be billed 
with a covered diagnosis. 
 
We looked at the file and Medicare rules. The documentation shows that code 64450 was billed with diagnosis 
codes G89.29, M53.3, M46.1, and M54.50. Diagnosis codes G89.29, M53.3, M46.1, and M54.50 are not listed 
as diagnosis codes that are covered for this service. This means code 64450 cannot be paid as billed. Based on 
this information, we decided that Medicare rules for coverage of the injection services have not been met. 
Therefore, we decided that the Plan does not have to pay for the injection services billed with code 64450 for 
date of service October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for November 21, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that pre-operative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code 99222 was related to and billed on the same day as 
minor procedure 11721. Payment for code 99222 is included in the global surgical payment for code 11721. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222 billed for November 21, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says that a CT scan of the 
heart is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the heart. Our reviewer 
says that a CT scan of the heart is not medically necessary. Our physician reviewer found that the request is 
medically necessary. Our reviewer found that a chest CT is an integral part of pre-operative evaluation for an 
aortic valve replacement. 
 
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 CT scan of the heart have not been met. Therefore, we decided that the Plan 
has to pre-approve a CT scan of the heart.  
 
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 28, 2022, to 
May 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you do not believe that the admit 
date on the NOA and the claim have to match. 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 28, 2022, to May 
27, 2022.