Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 11, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 11, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 11, 
2023, forward. Our reviewer says that the service is not medically necessary. Our physician reviewer found as 
of the last covered day, there is no indication in the available medical records that the enrollees psychiatric 
symptoms could not be managed on a less restrictive basis. As of the last covered day the enrollee did not 
express any active suicidal ideation or intent, or any intent to harm themselves or anyone else. The enrollee had 
no acute psychiatric issues that would require continued inpatient care.  The enrollee has chronic 
symptoms. The enrollee was not noted to be having any adverse reactions to medications or electroconvulsive 
therapy. The available medical records do not support that continued inpatient care will change these symptoms 
or the enrollees current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 11, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 11, 2023, 
forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a saddle bag, a cup holder, and a transit kit. 
 
You asked the Plan to pre-approve a saddle bag, a cup holder, and a transit kit. You say that the records 
provided support the need for the items which remain in dispute.  The Plan denied your request. The Plan says 
the items which remain in dispute serve comfort or convenience functions and do not constitute medical 
equipment.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a saddle bag, a cup holder, and a transit kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 28, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 28, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from June 28, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of June 28, 2023, forward. Our physician reviewer found 
the enrollee did not require inpatient mental health treatment beyond June 28, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 28, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 28, 2023, 
forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
thyroidectomy and will need inpatient admission after surgery The Plan denied your request. The Plan says 
there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provided records did not clearly show the enrollee with an unstable 
condition or high-risk history that would expect the enrollee to require hospital care following the surgery that 
would likely cross 2 midnights to support this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital admission provided on March 
6, 2023, to March 22, 2023. 
 
You asked the Plan to pay for inpatient psychiatric hospital admission. You say that this inpatient admission 
was medically necessary. The Plan denied your request. The Plan says this admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient psychiatric hospital admission. Our 
reviewer says that this admission was not medically necessary. Our physician reviewer found upon review the 
records provided for the admission of this enrollee does not meet the criteria for March 20, 2023, forward as 
this enrollee was not shown to be a danger to herself or others, delusions, auditory or visual hallucinations 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital admission have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient psychiatric hospital admission provided on March 6, 
2023, to March 22, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee under code G0453.
You asked the Plan to pay this claim The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial for codes 95938 and 95939. The Plan requested a reopen and provided documentation to show these codes were previously paid.
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, we have confirmed that code G0453 is a column II code to column I code 95957. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0453 billed for date of service June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 14, 2022, billed 
with codes 81209, 81218, 81272, 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
December 14, 2022, billed with codes 81209, 81218, 81272, 81314 and 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service D7999. 
 
You asked the Plan to pre-approve the dental service D7999. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental service D7999.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of acute or subacute T12 compression fracture on the 
imaging 
studies that were provided. There is no documentation of a reasonable trial of non-surgical management. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet coverage criteria. Our physician reviewer found detailed documentation is not 
evident regarding formal diagnostic studies corroborating an acute or subacute compression fracture at the T12 
level. The magnetic resonance imaging from May 5, 2023, did not demonstrate a compression fracture at this 
level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lateral trunk support, lateral trunk support hardware, and 
the lateral trunk support hardware extra link, brake extension handles, heel loop, folding backrest, bodilink 
head support hardware, and mounting block 18W. 
 
You asked the Plan to pre-approve lateral trunk support, lateral trunk support hardware, and the lateral trunk 
support hardware extra link, brake extension handles, heel loop, folding backrest, bodilink head support 
hardware, and mounting block 18W. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested items 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 lateral trunk support, lateral trunk 
support hardware, and the lateral trunk support hardware extra link, brake extension handles, heel loop, folding 
backrest, bodilink head support hardware, and mounting block 18W. Our reviewer says that the requested items 
are not considered medically reasonable and necessary in this case. Our physician reviewer found a face-to-face 
was completed. The documentation shows that you do not have stamina outside the room due to decline in 
physical and cognitive status, weakness, and fall risk. The documentation does not support that you require 
lateral trunk supports other than those already included in the custom back cushion. The documentation does 
not reveal that you are unable to use standard brake handles; therefore, brake extension handles exceed your 
medical need. The documentation does not reveal that standard foot rests do not meet your medical needs; 
therefore, heel loops are not medically necessary. The documentation does not reveal that the approved 
headrest hardware do not meet your medical needs; therefore, the Bodilink head support hardware exceeds 
your medical needs. The documentation does not reveal that you require a folding back rest in additional to the 
already approved wheelchair with tilt and custom back cushion. Therefore, you do not meet criteria for the 
requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lateral trunk support, lateral trunk support hardware, and the lateral trunk 
support hardware extra link, brake extension handles, heel loop, folding backrest, bodilink head support 
hardware, and mounting block 18W have not been met. Therefore, we decided that the Plan does not have to 
pre-approve lateral trunk support, lateral trunk support hardware, and the lateral trunk support hardware extra 
link, brake extension handles, heel loop, folding backrest, bodilink head support hardware, and mounting block 
18W.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided on November 17, 2022.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says your $750 dental benefit was exhausted prior to this date of service Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your $750 dental was exhausted prior to the date of service in question. Therefore, we decided the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve oncology gene expression profile by real-time RT-PCR of 3 genes.  
 
You asked the Plan to pre-approve oncology gene expression profile by real-time RT-PCR of 3 genes. You say 
that the requested oncology gene expression profile by real-time RT-PCR of 3 genes is medically necessary. 
The Plan denied your request. The Plan says that he requested oncology gene expression profile by real-time 
RT-PCR of 3 genes does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that oncology gene expression profile by real-time 
RT-PCR of 3 genes is covered when the criteria listed in the Medicare rules section of this decision are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve oncology gene expression profile by 
real-time RT-PCR of 3 genes. Our reviewer says that the requested oncology gene expression profile by real-
time RT-PCR of 3 genes is considered medically necessary in this case. Our physician reviewer found that the 
enrollee does meet both number 1 (no other relative indication for prostate biopsy) and number 2 
(no other relative contraindication).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oncology gene expression profile by real-time RT-PCR of 3 genes have been 
met. Therefore, we decided that the Plan has to pre-approve oncology gene expression profile by real-time 
RT-PCR of 3 genes.   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T7 and T8 kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve T7 and T8 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria. The documentation does not note greater 
than 25% vertebral body height reduction. The documentation notes retropulsion with moderate to severe 
spinal canal stenosis. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve T7 and T8 kyphoplasty. Our reviewer 
says that the enrollee does not meet coverage criteria. Our physician reviewer found there is fracture 
retropulsion which is a contraindication to kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T7 and T8 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T7 and T8 kyphoplasty (22513, 22515).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on October 17, 2022.

You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee.

The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when medically reasonable and necessary according to the criteria in the rules section of this letter.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the definitive UDT for 15-21 drug classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found there was no indication for multi-class drug testing. There is no history of drug abuse, diversion or early medication refills. The urine tests show only the prescribed medication. The testing was not medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the definitive UDT for 15-21 drug classes have not been met. Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 17, 2022, billed 
with procedure code 72125. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed units exceed the allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the imaging services provided have 
been met. Specifically, medical records have not been provided for review. Therefore, we decided that the Plan 
does not have to pay for imaging services provided on November 17, 2022, billed with procedure code 72125.