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

We decided that the Plan does not have to pay for anesthesia service (01402-QZ) provided on June 9, 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 for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan demonstrated that guidelines say when duplicate anesthesia codes are reported by the same or different physician or other qualified health care professional for the same patient on the same date of service, only the first submission of that code will be reimbursed. The guidelines also say anesthesia administration services can be rendered simultaneously by a physician and a CRNA during the same operative session by reporting modifiers QK or QY and QX. These services were rendered by the same provider and the modifier used was QZ. The NPI number for the rendering provider was the same for both claims and there was no separate modifier billed to identify the denied claim as anesthesia administration during a separate/distinct operative session. Therefore, this claim was denied as being coded incorrectly.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid due to the omission of a required modifier showing this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for anesthesia service (01402-QZ) provided on June 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from January 8, 2022, to February 2, 2022.
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. 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 January 8, 2022, to February 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient therapies provided on June 24, 2022.
You asked the Plan to waive the coinsurance for the outpatient therapies. You say that you met your out-of-pocket maximum. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
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 20% coinsurance for outpatient rehabilitation services. You have been asked to pay a 20% coinsurance for the outpatient therapies.
This item/service falls within the outpatient rehabilitation 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 coinsurance for the outpatient therapies provided on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) services for the enrollee.
You asked the Plan to pre-approve bioimpedance spectroscopy services. You say that the enrollee was diagnosed with breast cancer and underwent left breast biopsy. The Plan denied your request. The Plan says that a review of the current medical literature does not consider this service to be standard medical treatment for the diagnosis of lymphedema. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bioimpedance spectroscopy services. Our Medical Director states that at the time of the Plan's denial, the NCCN Guidelines Version 1.2022 Survivorship: Lymphedema did not recommend BIS in the management of lymphedema. The available evidence in the medical literature was insufficient to support that bioimpedance spectroscopy was then medically reasonable and necessary. Our physician reviewer found that the enrollee's condition does not met criteria for coverage of bioimpedance spectroscopy services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bioimpedance spectroscopy services have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the home health services provided from 
September 20, 2022, through October 8, 2022. 
 
You asked the Plan to make additional payment for the home health services. You say that the claim should be 
paid as billed.  The Plan denied your request. The Plan says payment was reduced for this home health claim as 
several of the items from the OASIS assessment are not supported.  
The Plan follows Medicare rules. Medicare rules say that payment for home health services is based on a case-
mix methodology which is adjusted based in part on information from the OASIS assessment.  
 
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 make additional payment for the home health 
services. Our reviewer says that the provided records do not fully support that the enrollee was entirely 
dependent (score of 3) for the Section M1800, M1810, and M1820 skills, grooming, upper body dressing, and 
lower body dressing. Our physician reviewer found some provided records reported the enrollee was modified 
independent for these tasks and other reports indicated the enrollee needed some assistance with these 
activities. The enrollee was also reported to live alone with periodic help from family, which does not support 
the assessment that she was entirely dependent for grooming, upper body dressing, and lower body dressing. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to make additional payment for the home health services provided from September 20, 2022, 
through October 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with PDPM 3BB21 provided 
on October 7, 2021. 
 
You asked the Plan to pay for the home health services as billed. 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 follows Medicare rules. Medicare rules say that home health services must be billed with the correct 
PDPM. 
 
We asked our 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 home health services as billed. Our reviewer says that 
the documentation does not support the PDPM billed. Our physician reviewer found the enrollee has a medical 
history including hypertension and previous stroke who received home healthcare services. The documentation 
available for review did not include a Start of Care OASIS or any components of the initial comprehensive 
assessment. The documentation required including a Start of Care was not provided to give an accurate 
description of the functional impairment. Therefore, the PDPM billed is not supported. 
 
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the home health services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services billed with PDPM 3BB21 provided on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 26, 2022 and billed under code 87086.

You asked the Plan to pay this claim. You say that the Plan should cover this testing.  The Plan denied your request. The Plan says the Medicare billing criteria were not me. Maximus overturned the Plans denial. The Plan requested a reopen and noted that this claim was denied because these services were not billed with an appropriate diagnosis. The service was billed with diagnosis code Z87.440 for Personal history of urinary (tract) infections. Medicare does not cover this testing for screening purposes. 

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 testing was not billed with a valid diagnosis code that allows coverage. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 26, 2022, and billed code 87086.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you cannot take do daily living things, cannot move 
around to use bathroom or feed yourself, and at risk with falls. The Plan denied your request. The Plan says 
your records do not show that your rehabilitation needs are complex and that you need to be seen 3 times per 
week for evaluation of functional and medical goals and progress. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology office visit provided on May 26, 2022 under Claim A and code 99213.
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. The Plan requested a reopen and noted that Claim A denied because the Plan previously paid for this service under another claim by the same provider on the same date of service. This service was previously paid under Claim B for the same date of service to a provider in the same physician group.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems.
Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for the dermatology office visit provided on May 26, 2022 under Claim A and code 99213.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leads for use with a neuromuscular stimulator provided 
on December 7, 2022.  
 
You asked the Plan to pay for the electrical leads. You say that the items should both be reimbursed.  The Plan 
denied your request. The Plan says payment cannot be made for supplies while the equipment is being rented. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of supplies needed for the use of 
DME can only be covered when the DME is owned by the enrollee.  
 
We looked at the file and Medicare rules. As the enrollee is renting the DME at issue, the separate payment 
cannot be made for the supplies. Based on this information, we decided that Medicare rules for coverage of the 
electrical leads have not been met. Therefore, we decided that the Plan does not have to pay for the leads for 
use with a neuromuscular stimulator provided on December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no new order from the physician for continuation of services beyond the initial home health episodic care.
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 home health services have been met. There is not a verbal request for continuation of services for a second 60-day period of home health services. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intensive therapy 5 to 6 hours a 
day. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
admission to an IRF. 
 
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 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 enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
this patient 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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone density scan provided to the enrollee on August 4, 2022 and billed under code 77080.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plan denial. The Plan requested a reopen and demonstrated that this claim denied because this service was not billed with an appropriate diagnosis code. The Plan notes the Medicare guidelines state claims for bone density screening tests that do not contain a valid diagnosis code will be denied.
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 was not submitted with a valid diagnosis code. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for a bone density scan provided to the enrollee on August 4, 2022 and billed with code 77080.
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 it is not safe for you to return home and SNF 
services are necessary for you to build up your strength, endurance, and stability. The Plan denied your request. 
The Plan says the SNF services requested do not meet the requirements for approval.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve irreversible electroporation (IRE) with NanoKnife. 
 
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 enrollee has recurrent prostate 
cancer and had initial treatment with radiation in 2005. Recurrent disease was confirmed by biopsy on February 
11, 2022. The use of IRE with NanoKnife is considered experimental/investigational in nature for the treatment 
of prostate cancer due to insufficient evidence in peer-reviewed literature. The services are 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 irreversible electroporation (IRE) with NanoKnife.
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. The Plan denied your request. The Plan says the enrollee does not 
require three times weekly physician visits for medical management. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.