Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87186 and P9603 billed for date of service 
April 11, 2023. 
 
You asked the Plan to pay for procedure codes 87186 and P9603. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
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 87186 is susceptibility studies, antimicrobial agent; 
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-
antimicrobial, per plate. The CPT code manual definition of code P9603 is travel allowance one way in 
connection with medically necessary laboratory specimen collection drawn from home bound or nursing home 
bound patient; prorated miles actually travelled. 

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 procedure codes 87186 and P9603. Our reviewer says that 
these codes are not supported as billed. Our reviewer found that the laboratory report does not include 
documentation to support 12 units of 87186. Specifically, when testing for the same organism on the same 
plate, it would not be appropriate to report this code more than once. In addition, the records do not include 
documentation of travel, and therefore procedure code P9603 and the number of units billed 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 procedure codes 87186 and P9603 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87186 and P9603 billed for date of service April 11, 
2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nor provide future coverage for skilled nursing facility (SNF)
care that began on January 7, 2023.

You asked the Plan to provide previous coverage and future coverage for SNF care. You say that the Plan
should cover these services. The Plan denied your request. The Plan says the enrollee did not have prior
authorization and the required Medicare coverage criteria were not met. Maximus partially overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.

The Plan is correct in this case. 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. The
Plan contract states that prior authorization may be required. The enrollee was admitted to the facility on
January 7, 2023. The enrollee did not have prior authorization. An appeal for services to be covered was not
received by the Plan until March 10, 2023. Based on the records provided, the enrollees care needs were
custodial in nature which is not covered by Medicare. Therefore, we decided that the Plan does not have to pay
for previous coverage and provide future coverage for skilled nursing facility (SNF) care that began on January
7, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for thyroxine (84439) and thyroid stimulating hormone (TSH) (84443) provided July 21, 2023.

You asked the Plan to pay for the laboratory testing. You say that please review denied codes with supporting documentation. The Plan denied your request. The Plan says screening tests without a valid medical diagnosis related to the health of the patient are not a benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for thyroxine (84439) and thyroid stimulating hormone (TSH) (84443) provided July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve an electronic connection. You say that you are requesting reconsideration of
the denied authorization. The Plan denied your request. The Plan says that this item is not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection. Our Medical Director states that the documentation supports that the enrollee's upper extremity
strength and function appear to be adequate to operate the power options using their own switches. Our
Medical Director found that the enrollee's condition does not meet criteria for coverage of an electronic
connection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan
does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator.

You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan
denied your request. The Plan says that the requested device is not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a ventilator. Our
Medical Director states that you have a medical history that included COPD with chronic respiratory failure
and hypoxia, as well as obstructive sleep apnea, hypertension, and pulmonary hypertension. It is noted that you
had a difficult time tolerating the pressure of your BiPAP. The documentation does not support that the
coverage criteria were met in this case. Medicare rules state that payment policy requirements preclude FSS
payment for devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the
illness treated by the device. This means that products currently classified as HCPCS code E0465 or E0466
when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying
medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement
for any of the conditions described in this Medicare rule even though the ventilator equipment may have the
capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or
bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and
necessary. Our Medical Director found that your condition does not meet criteria for coverage of a ventilator.

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 ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on July 20, 2023.

You asked the Plan to waive the copayment for an office visit. You say that this was a follow-up visit. 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 services from a specialist.

You have been asked to pay a $35 copayment for an office visit. This item/service falls within the services from a specialist 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 an office visit provided on July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640-59 billed for date of service August 3, 
2023. 
 
You asked the Plan to pay for procedure code 87640-59. You say that this service was necessary and was 
reported appropriately for separate payment. The Plan denied your request. The Plan says the use of the 59 
modifier is not supported with this code; therefore, the payment for this service is included in the payment for 
87641. 
 
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 procedure code 87640-59. Our reviewer says that this code is 
not supported for separate payment. Our reviewer found that the laboratory report does not include 
documentation to support a separate procedure. CPT 87641 includes Staphylococcus aureus. Therefore, this 
procedure 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 procedure code 87640-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87640-59 billed for date of service August 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan noted that the medical records show at the time of the appeal, the enrollee's ability to
participate in intensive therapy was limited by the new below the knee right leg amputation, as well as
documented weakness and resistance to therapy while in the hospital.

The Plan is correct in this case. 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.
Based on the medical records provided, at the time of the appeal, the documentation does not show the enrollee
met the required Medicare criteria for IRF admission. Whether or not admission was beneficial was not of
issue. The enrollee must meet the required criteria for coverage prior to admission. Therefore, we decided that
the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and
services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan noted the medical records show your ability to participate in intensive therapy was
limited by weakness, dizziness, and the sacral wound vacuum in place at the time of the appeal. The Plan also
stated the records show after four months in a long-term acute care hospital, the documentation does not show
there was a reasonable expectation for significant improvement at an IRF facility.

The Plan is correct in this case. 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. Based
on the medical records provided, there was not a reasonable expectation that you would be able to participate in
or benefit from a rehabilitation program of at least 3 hours a day for 5 days a week. Medicare rules for
coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage
for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically beneficial for the enrollee. The Plan denied your request. The Plan says the Medicare coverage
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria. The Plan noted that the medical records indicate there was not a
reasonable expectation that the enrollee could participate in an IRF level of rehabilitation. The medical records
show the enrollees participation in hospital therapy was hampered by weakness, abdominal pain, and
complaints of weakness and fatigue.

The Plan is correct in this case. 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.
Based on the medical records provided, the enrollee's endurance issues and complaints at the time of the appeal
did not demonstrate that the enrollee was willing to or would be able to participate in therapy for a minimum of
3 hours a day for 5 days a week. The enrollees care needs did not require and IRF level of care. At the time of
the appeal, Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to
provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services billed with code 88305 billed for
August 31, 2022.

You asked the Plan to pay for this claim. You say that these services 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 for insufficient information in the case file. The Plan requested a reopen and provided additional claim
information. The Plan demonstrated that the Medicare guidelines state according to the code descriptor changes
for HCPCS code G0416 effective January 1, 2015, Medicare requires that surgical pathology, including gross
and microscopic examination, of any and all submitted prostate needle biopsy specimens from a single patient
be reported with one unit of service of under code G0416 rather than code 88305. The records show the
enrollee had a prostate needle biopsy done on the same day, therefore the appropriate pathology code should be
billed. The guidelines state when a needle biopsy is performed, the pathology of that biopsy must be billed with
G0416.

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.

In this case, this claim could not be paid as billed due to the submission of an inappropriate code. This claim
should have been billed with code G0416 instead of code 88305. Therefore, we decided that the Plan does not
have to pay for surgical pathology services billed with code 88305 for August 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to make an exception to the 50-mile one-way limit for routine
transportation.

You asked the Plan to make an exception to the transportation mile limit. The Plan denied your request. The
Plan says the requested provider is beyond the 50-mile routine transportation limit. Maximus overturned the
Plans denial for insufficient information in the case file regarding the provider's address. The Plan requested a
reopen and submitted the required information.

The Plans additional information shows you are requesting transportation from your address, 908 Central
Avenue, #15 Kremmling, CO 80459 to the Avon Dental office address, 50 Buck Creek Road, Suite 305 Avon,
CO 81620. Based on Google Maps, the Plan verified the shortest route to the providers office is 51.4 miles
which exceeds the 50-mile limit.

The Plan is correct in this case. Medicare does not cover transport in a vehicle that is not an ambulance.
However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's
coverage rules apply in this case. The Plan covers routine transportation however each one-way trip must not
exceed 50 miles of driving distance. Based on Google Maps, the provider is 51.4 miles from your address.
Based on this information, this exceeds the Plans one way trip mileage limit. Therefore, we decided that the
Plan does not have to make an exception the 50-mile one-way limit for routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct criteria. The Plan noted that at the time of the appeal, the medical records show the
enrollee's ability to participate in intensive therapy was described as limited by the weight bearing/activity
restriction and their fatigue per the hospital physical therapist.

The Plan is correct in this case. 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.
Whether or not an IRF admission may be beneficial for an enrollee as time progresses is not of issue. The
enrollee must be able to participate in and benefit from a rehabilitative program to consist of at least 3 hours of
therapy a day for 5 days per week. Based on the medical records provided, the enrollee did not meet these
criteria at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466) for the enrollee.

You asked the Plan to pre-approve a home ventilator. You say that without non-invasive ventilator therapy, the
enrollee is at high risk for hospital admission and potentially life-threatening exacerbations. The Plan denied
your request. The Plan says that the request for continued use of a device to assist with breathing coded as
E0466 does not meet the requirements for approval. Maximus partially overturned the Plan's denial. The Plan
requested a reopening and states that the enrollee did not meet criteria for coverage.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as
not reasonable and 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 home ventilator. Our reviewer says
that a home ventilator is not medically reasonable and necessary for the enrollee. This patient has diagnoses of
COPD, HFpEF, pulmonary hypertension, obesity hypoventilation syndrome, and obstructive sleep apnea.
Pulmonary function tests consisting of spirometry in September of 2022 suggested moderate restrictive lung
disease. The FEV1 was 61% of predicted on poor quality spirometry, with a normal FEV1/FVC ratio. The
diffusing capacity was severely reduced. Thus, if there is COPD, it is not severe, and would not be expected to
cause chronic CO2 retention. There is no diagnosis of thoracic restrictive disease or neuromuscular disease.
During hospitalization in July 2022, for congestive heart failure and exacerbation of COPD, there was mild
CO2 retention with a PaCO2 of 52. This normalized to 44.6 later in the hospitalization. The patient was
prescribed a home ventilator upon discharge from the 2022 hospitalization and has been using it with excellent
compliance. There is no evidence in the medical record that the patient was tried on BiPAP as an outpatient.
This patient would likely benefit from BiPAP with AVAPS as an outpatient. Medicare does not cover a home
ventilator in the treatment of obesity hypoventilation syndrome, or when used at settings that can be provided
with BiPAP. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a
home ventilator.

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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator (E0466) for the enrollee.