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

 
We decided that the Plan has to pay for Nodify CDT (81599) provided on October 20, 2022. 
 
You asked the Plan to pay for Nodify CDT. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Nodify CDT have been 
met. Therefore, we decided that the Plan has to pay for Nodify CDT (81599) provided on October 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 31, 2022. 
 
You asked the Plan to pay for the physician's services. You say that your PCP was, and is, on the preferred 
provider list at the time of service. You says that you were seen by the physicians assistant at this visit. The 
Plan denied your request. The Plan says your plan excludes coverage for this out-of-network service. It was 
confirmed that the M.D. is a non-contracted provider. The services were not urgent/emergent in nature. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service December 
13, 2022.  
 
You asked the Plan to pay for procedure code 88321. You say that this should be paid.  The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service April 29, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says the payment for these services is 
included in the payment for other services provided on the date in question. 
 
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 87481, 87653 and 87798 is a column II code to column I code 87801. 
Codes 87481 and 87653 have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met for codes 87481 and 87653. However, code 87798 
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 87798. Our reviewer says that separate 
payment is not supported for this service. Our reviewer found the provided records in this case document a 
urinary tract infection panel with antibiotic resistance, but records do not support modifier 91 (repeat clinical 
diagnostic laboratory test is used to report the same lab test when performed on the same patient, on the same 
day, to obtain subsequent test results). As modifier 91 is not supported in this case, the NCCI edit bypass is not 
supported. 
 
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 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99153 provided to the enrollee on April 29, 2022.
You asked the Plan to pay for these services. You say that is claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met.
Maximus partially overturned the Plans denial. The Plan requested a reopen and provided documentation to show codes 45385 and G0500 were paid.
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that code 99153 is a PE only code and that PE are not payable to the physician for services provided in the facility setting. We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for code 99153 provided on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory pathogen testing (87496, 87498, 87502 and 87532) provided on June 28, 2022.
You asked the Plan to pay for this claim. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for sufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that this claim denied because these services were inappropriately billed. The provider billed codes 87496, 87498, 87502 and 87532, which are viral codes. They were individually submitted. The provided should have submitted this service as a single bundled code.
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 as these services are included in a single panel which would be submitted under a single code. Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for respiratory pathogen testing (87496, 87498, 87502 and 87532) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 99190, 99191, 99192, 86891 and P9022 billed for date of service May 18, 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 partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that non-physician services furnished to inpatients must be furnished directly by the hospital or under arrangements. Service codes 86891 and P9022 rendered by certified clinical perfusionists (CCP), are non-physician services. Per Medicare, non-physician services provided to a Part A inpatient or Part B inpatient of a hospital or to a Part A inpatient of a skilled nursing facility (SNF) which are not provided directly by the hospital/SNF or under arrangement generally are excluded from coverage under Medicare. Perfusionists services are not included as part of the exceptions to this non coverage rule. A non-physician service is one which does not meet the criteria defining physicians' services specifically provided for in regulation at 42 CFR 415.102. Services "incident to" physicians' services (except for the services of nurse anesthetists employed by anesthesiologists) are nonphysician services for purposes of this provision." All items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of whether they are subject to PPS.
Per the Medicare guidelines, the Plan correctly denied the services for payment as they are non-physician services furnished to inpatients and must be furnished directly by the hospital or under arrangements.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim cannot be paid as billed as payment for these services would be the responsibility of the facility and not separately billed to the Plan. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for codes 99190, 99191, 99192, 86891 and P9022 billed for date of service May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services provided to the enrollee from August 9, 2022, to August 10, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that this service was billed with an inappropriate Place of Treatment (POT) code. The claim that was billed with POT 61 which indicates services were rendered through a Comprehensive Inpatient Rehabilitation Facility. However, the provider needed to bill the POT 21 which shows services provided at an Inpatient Hospital. We found that POT 21 is used when a facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. The enrollee was admitted for inpatient stay due to low back pain and paresthesia of skin. This was not a part of a psychiatric facility, which makes POT 61 for Comprehensive Inpatient Rehabilitation Facility not applicable for the services rendered.
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 an error with the POT code. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for evaluation and management services provided to the enrollee from August 9, 2022, to August 10, 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 you had an amputation, and you need IRF services. The Plan denied your request. The Plan says that the admission to an IRF is not medically necessary. 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 IRF care. Our Medical Director states that the clinical documentation is insufficient to support that it was reasonable to expect that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary. 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 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 have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing 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 skilled nursing facility (SNF) care.
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 is motivated to participate in therapy and 
improve. The Plan denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 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 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 therapy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker (E1399). 
 
You asked the Plan to pre-approve an upright walker. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there is no indication the upright walker is medically necessary over the 
already approved heavy-duty walker. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have been approved for a heavy-duty walker. This serves the same purpose as an 
upright walker. Therefore, we decided that the Plan does not have to pre-approve an upright walker (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely discharged home. They 
require IRF services in order to get stronger and be less of a fall risk. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is medically necessary testing.  The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 5, 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 is ready to be admitted to an IRF. The 
Plan denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 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 therapy 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: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for code 36589 billed for date of service August 29, 2022.
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 stated that Maximus did not apply the correct billing criteria. The Plan stated that the denial did not involve a status indicator as decided by Maximus. The denial shows surgery procedure 36589 has a global surgery value of 010 on the National Physician Fee Schedule Relative Value file. This is a minor procedure that has a global surgery period of 10 days. Payment for code 36589 billed for August 29, 2022, would be included in the global surgery package for code 36558 billed for August 19, 2022.
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 due to the global billing period for the codes billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 36589 billed for date of service August 29, 2022.