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 prior to your hospitalization you were living 
independently and now you are unable to. The Plan denied your request. The Plan says you do 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 enrollee's nursing, medical, and rehabilitation needs can be 
provided in a lower level of care, and it does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee requires treatment by multiple therapies, 
including physical therapy and occupational therapy, but this can be provided 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve the nerve blocks. You say that you are in severe pain and require this 
procedure to regain the ability to do everyday activities. The Plan denied your request. The Plan says the 
request 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 the nerve blocks. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 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 nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genicular nerve blocks.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93925 rendered on August 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 93925 rendered on August 22, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 93925 is "Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation shows that CPT 
93925 was ordered and performed on both of the lower extremities. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 93925 rendered on August 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 13, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83520 is "Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified". 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, the lab order/requisition did 
not include what laboratory test was ordered in order to validate the billed not otherwise specified code. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99204, 62323, and J3301 provided on April 6, 2023. 
 
You asked the Plan to pay for procedure codes 99204, 62323, and J3301. 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 
supported. 
 
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. In this case, the Plan denied payment for services due to the lack of the servicing 
provider name on the medical records for verification. However, the Plan has provided no documentation 
showing they made any attempts to obtain these specific documents. Therefore, we decided that the Plan has to 
pay for procedure codes 99204, 62323, and J3301 provided on April 6, 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 Urine PCR panel provided February 1, 2023, billed with 
codes 87481, 87653, 87798, 87801. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim.  
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 looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel provided 
February 1, 2023, billed with codes 87481, 87653, 87798, 87801.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says the service cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code J3490 was billed to identify Bupivacaine, a local 
anesthetic. If performed to facilitate the infusion or injection or hydration, the use of local anesthesia is 
included and not separately billable. 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 
code J3490 billed for date of service June 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided on May 19, 2022, to June 17,
2022.

You asked the Plan to pay for these services. 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 noted that the case file submitted to Maximus contained a clerical error which
advised the NOA claim was received on June 17, 2022. This was incorrect. The NOA claim
was received on October 25, 2022, which was past the 30-day allowable submission period.
This was the only valid NOA claim that the plan received.

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 the submission of an invalid
NOA. 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 on May 19, 2022, to June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves
(E0667) for the enrollee.

You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that the records
provided support that the requested items are medically necessary. The Plan denied your request. The Plan says
that there is no evidence of a four-week trial of conservative therapy.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a pneumatic
compression device and sleeves. Our Medical Director states that the documentation does not support that the
coverage criteria for an E0652 were met in this case. The enrollee did not fail a four-week trial of conservative
therapy that included at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651.
Our Medical Director found that the enrollee's condition does not meet Medicare criteria for a pneumatic
compression device and sleeves.

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 pneumatic compression device and sleeves have not been met. Therefore, we
decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves
(E0667) for the enrollee.
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 
June 28, 2023.  
 
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 June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Membrane Graft or Membrane Wrap, per sq cm 
(Q4205) and application of skin substitute graft; first 100 sq cm wound surface area (15273). 
 
You asked the Plan to pre-approve skin substitute. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 skin substitute. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature does not support the use of these agents for pressure ulcers, nor does it support use 
for 3-6 months, as proposed by the treating physician.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Membrane Graft or Membrane Wrap, per sq cm (Q4205) and application of skin substitute 
graft; first 100 sq cm wound surface area (15273).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that you are pleased with the therapists' service, 
and they are very familiar with your situation and have been working with your referring provider about your 
treatment plan. The Plan denied your request. The Plan says you receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames (V2020) and bifocals (V2204) provided on 
May 30, 2023. 
 
You asked the Plan to pay more for the frames and bifocals. You say that you do not agree with having to owe 
the $207.20 for the glasses. The Plan denied your request. The Plan says this claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 combined every year towards the cost of supplemental contact lenses, 
eyeglasses (lenses and frames), and upgrades. 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that the total cost of the glasses 
(including the frame and impact-resistant lined bifocal lenses with anti-glare and UV protection) totaled 
$509.00. After the 20% savings, the cost of the glasses was $407.20. The Plan applied the full $200 plan 
allowance toward this purchase, and you are responsible for the remaining $207.20. Based on this information, 
we decided that the Plan's rules for coverage of the frames and bifocals have not been met. Therefore, we 
decided that the Plan does not have to pay more for the frames (V2020) and bifocals (V2204) provided on May 
30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the immunotherapy injection provided on 
June 21, 2023. 
 
You asked the Plan to waive the copayment for the immunotherapy injection. You say that you were told this 
would be fully covered. 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 $35 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the immunotherapy injection. This item/service falls within 
the specialist physician/practitioner 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. However, since the allowed amount is less than the standard copayment, 
you only owe $11.39. Therefore, we decided that the Plan does not have to waive the copayment for the 
immunotherapy injection provided on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on April 4, 2023, billed with codes 
87481, 87491, 87653, 87640, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the testing billed. You say that the codes are approved by Medicare. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This NGS panel was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the panel testing provided on April 4, 2023, 
billed with codes 87481, 87491, 87653, 87640, 87798, 87641, and 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 3, 2022, billed with 
codes 81479, 81225, 81226,81232, 81231, 81241, 81328, 81227, 81240, 81306, 81291, 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you provide diagnosis and medical 
records for each claim and do not bill claims that do not have diagnosis related to the genetic test being 
performed. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim.  
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 3, 2022, billed with codes 81479, 81225, 81226,81232, 81231, 81241, 81328, 81227, 81240, 81306, 
81291, 81335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 1, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The genetic testing in this case is not covered per the DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 1, 2022.
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 would benefit from this care. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission and, the 
enrollee needs can be provided at another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. There is not a reasonable expectation 
that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. The enrollee's rehabilitation needs can be safely provided in an alternate setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.