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 IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs 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. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 the enrollee needs SNF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for SNF care. 
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgement of a skilled professional nurse. While the medical records show the enrollee 
does require skilled therapy services there is no documentation that these services are required on a daily basis. 
Further improvement in the enrollee's functional status does not appear to be predictable in a reasonable time 
frame to necessitate further daily skilled therapy services. Based on the medical records provided there is no 
documentation that the enrollee requires the services on an inpatient basis, only in a SNF setting. Records 
support that services in the home with home health care or in a long-term care facility on a part time basis are 
appropriate in this case. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on January 11, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter are met. 
 
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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
documentation does not support that testing for 22 or more drug classes was 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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services for an emergency department visit
provided to the enrollee on September 23, 2022.

You asked the Plan to pay for the physician services. You say that you have provided proof of enrollment from
CMS for this provider. The Plan denied your request. The Plan says that this provider has been precluded from
participation in Medicare at the time services were rendered. Maximus overturned the Plan's decision for
insufficient information in the case file. The Plan requested a reopen and provided documentation to show that
as of April 20, 2022, the provider is in an exclusion status for Medicare claims.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a physician or practitioner who has
opted out of the program except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the physician services for an emergency
department visit provided to the enrollee on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486 and 87532 billed for date of service 
December 9, 2022. 
 
You asked the Plan to pay for procedure codes 87486 and 87532. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 87486 and 87532 is bundled into 
payment for code 87801. 
 
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 codes 
87486 and 87532 are column II codes to column I code 87801. 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 codes 87486 and 87532 billed for 
date of service December 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service July 6, 2023.  
 
You asked the Plan to pay for procedure code G0480. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code G0480 is bundled into payment for code 80307. 
 
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 G0480 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. 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 G0480 billed for date of service July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional chiropractic visits. 
 
You asked the Plan to pre-approve the chiropractic services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic services. Our reviewer 
says that the request is not medically necessary. Our physician reviewer found the enrollee already had 36 
chiropractic visits in 2023. Further clinical improvement in the enrollee's symptoms of back, hip and thigh 
discomfort does not appear to be predictable in a reasonable time frame to necessitate further chiropractic 
treatments beyond the now 40 approved treatments this year. 
 
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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional chiropractic visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0480 and 83789 billed for date of service 
July 12, 2023.  
 
You asked the Plan to pay for procedure codes G0480 and 83789. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes G0480 and 83789 is bundled into 
payment for other codes. 
 
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 G0480 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. We have confirmed that code 83789 is a column II code to column I code 80307. While 
code 83789 was billed with modifier -59, the medical records provided do not show that the service billed with 
the -59 modifier is a distinct procedural service. 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 codes G0480 and 83789 
billed for date of service July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve and pay 
for these dentures. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 3, 2023. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary (D5110) and a complete 
mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair and additional 
items and accessories (E2363 x2, E1007, E2311, E2620, E2605, E1012, E0955, E1028 x2, E2377, E2313). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is a high fall 
risk, and the seat options recommended are necessary. The Plan denied your request. The Plan says the enrollee 
does not need tilt-in-space, elevating leg rests, or recline added to the new wheelchair. The Plan also says the 
ordering provider is not supportive of a group 3 power wheelchair. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of stroke and poor ambulation. She is able to 
stand and has intact skin. She does not use a catheter. Per L33789, the enrollee does not have high risk for skin 
breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing power 
drive. 
 
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 standard power wheelchair and additional items and 
accessories (E2363 x2, E1007, E2311, E2620, E2605, E1012, E0955, E1028 x2, E2377, E2313).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on July 31, 2023. 
 
You asked the Plan to pay for genetic testing. You say that no additional documentation should be needed for 
coverage. The Plan denied your request. The Plan says that this testing is not the standard of care and was not 
billed with the appropriate coding. 
 
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. 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Therefore, we cannot determine whether the lab order made constituted plan-
directed care. Additionally, the Plan based its coding denial on Local Coverage Article (LCA) A58917; 
however, this article does not pertain to the codes billed on this claim. Therefore, the Plan has not shown that 
its decision to deny payment for this testing is correct or justified. Therefore, we decided that the Plan has to 
pay for genetic testing provided on July 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87491, 87500, 87563, 87640, 
87641, 87653 and 87798) billed for date of service July 11, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not reported in accordance with 
Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87491, 87500, 87563, 87640, 87641, 87653 and 
87798) billed for date of service July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4215 billed for date of service June 13, 2023. 
 
You asked the Plan to pay for code A4215. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says procedure code A4215 is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that code A4215 has a status indicator of N on the Physician Fee Schedule. This means that code 
A4215 is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
code A4215 have not been met. Therefore, we decided that the Plan does not have to pay for code A4215 billed 
for date of service June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
6, 2023, to February 28, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you believe these services were 
medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, this request is 
not a covered benefit.  
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided February 6, 2023, to February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491-59 and 87640-59 provided July 10, 
2023. 
 
You asked the Plan to pay for the laboratory services . You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 services. Our reviewer found for code 87640, 
the documentation submitted was reviewed and does not meet criteria. The provider reported procedure code 
with appended modifier 59 distinct procedural service to bypass NCCI Edit with CPT 87641 Staphylococcus 
aureus, methicillin resistant. Furthermore, for code 87491, the documentation submitted was reviewed and does 
not meet criteria. After careful review of the laboratory report and physician order, documentation does not 
support service billed. Laboratory report does not include testing and result for Chlamydia trachomatis, as well 
as physician order does not include procedure to be performed. In this case, this procedure cannot be verified. 
However, the laboratory report does not include documentation to support separate billing, and therefore, the 
procedure code and modifier cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87491-59 and 87640-59 provided July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0480 and 83789 billed for date of service 
July 11, 2023.  
 
You asked the Plan to pay for procedure codes G0480 and 83789. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes G0480 and 83789 is bundled into 
payment for other codes. 
 
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 G0480 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. We have confirmed that code 83789 is a column II code to column I code 80307. While 
code 83789 was billed with modifier -59, the medical records provided do not show that the service billed with 
the -59 modifier is a distinct procedural service. 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 codes G0480 and 83789 
billed for date of service July 11, 2023.