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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 24, 2022, to 
October 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
hemiplegia, unspecified affecting left nondominant side, and chronic lymphocytic leukemia of B-cell type not 
having achieved remission are the correct secondary diagnoses. The Plan denied your request. The Plan says 
the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported 
inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, G81.94, defined as 
hemiplegia, unspecified affecting left nondominant side and the secondary diagnosis code, C91.10, defined as 
chronic lymphocytic leukemia of B-cell type not having achieved remission. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
the enrollee was evaluated for transient left-side weakness, not left-side paralysis. While it is documented that 
the enrollee had a history of chronic lymphocytic leukemia (CLL), it is unknown whether the enrollees CLL 
was in remission, and there is no evidence that the diagnosis played a role during the hospitalization. As such, 
the billing of G81.94 and C91.10 is the not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 24, 2022, to October 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay for one D0274 and D1110. We decided that the Plan does not have to pay 
for the additional three D0274.  
 
You asked the Plan to pay for four bitewings (D0274) and prophylaxis (D1110) provided on April 6, 2023. 
You say that this was an emergency. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
We decided that the Plan has to pay for one D0274 and D1110.  
 
 Evidence was not provided to verify that D0274 and D1110 were previously provided. Therefore, we decided 
that the Plan has to pay for one D0274 and D1110.  
 
We also decided that the Plan does not have to pay for three D0274. 
 
One D0274 is allowed every 12 months. Therefore, we decided that the Plan does not have to pay for the 
additional three D0274. 
 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional occupational therapy visits for the
enrollee.

You asked the Plan to provide coverage for additional occupational therapy visits. You say that at the time of
the appeal, these services were medically necessary. The Plan denied your request.

The Plan says the criteria for continued coverage are not met. Maximus upheld the Plans denial. The Plan
requested a reopen to confirm the correct services were reviewed as the original Maximus decision stated
physical therapy was the issue. The case was reopened, and occupational therapy was addressed.

The Plan remains correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays
for medically necessary outpatient therapy such as occupational therapy. 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 provide coverage for additional occupational therapy visits. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. The enrollee has received 25 sessions of occupational therapy. He continues to require some degree
of supervision and assistance with mobility, but his motor strength has not significantly changed, and he no
longer requires the services of a skilled occupational therapist. The enrollee an continue with a home exercise
program or receive supervision from a non-skilled person for fall prevention if needed. Medicare criteria for
additional occupational therapy visits are not 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 additional occupational therapy visits have not been met. Therefore, we decided
that the Plan does not have to provide coverage for additional occupational therapy visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053) provided on May 2, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 80053 is not supported in the medical record. Specifically, the medical records 
submitted references Clinical Laboratory Improvement Amendments (CLIA) number 18D1092600. The claim 
form references a different CLIA number, 05D0580198. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (80053) provided on May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) device, and related supplies provided on June 19, 2023, to August 09, 2023. 
 
You asked the Plan to waive the coinsurance for a continuous positive airway pressure (CPAP) device, and 
related supplies. You say that you do not agree with the charges. 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 20% 
coinsurance for out-of-network oxygen and oxygen related equipment. 
 
You have been asked to pay 20% coinsurance for a continuous positive airway pressure (CPAP) device, and 
related supplies. This item/service falls within the out-of-network oxygen and oxygen related equipment 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. The 
total you owe is $88.27 ($441.39 allowed amount x 20% = $88.27 rounded down). Therefore, we decided that 
the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device, and 
related supplies provided on June 19, 2023, to August 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH.  The Plan denied your request. 
The Plan says  the enrollee does not meet the Medicare criteria for LTACH services.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you do not understand why the Plan is denying this 
CGM. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that the VivAer procedure is a Food and 
Drug Administration (FDA) cleared technology and is medically necessary. The Plan denied your request. The 
Plan says the VivAer procedure is considered experimental and investigational because the effectiveness of 
these approaches have not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that the provided medical records and review of the current peer-reviewed medical 
literature do not document that use of the VivAer procedure has been shown in controlled studies in a CMS-approved journal to result in sustained long term health benefits in patients with nasal obstruction. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 8, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on September 12, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
unit of one code as required by LCA A58726 Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on September 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hoveround personal mobility device (E1399). 
 
You asked the Plan to pre-approve a Hoveround device. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval 
of the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your 
condition can be improved by a walker, cane or manual wheelchair and you cannot safely operate the PMD 
being requested. The file does not show a standard written order with a detailed description of the exact device 
being requested. Specifically, you do not meet criteria for the requested device. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Hoveround personal mobility device (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services coded as 98941 performed on 
October 28, 2021, through December 23, 2021.  
 
You asked the Plan to pay for the chiropractic services. You say that the chiropractic services should be 
covered because they were billed accurately. The Plan denied your request. The Plan says the chiropractic 
services are denied because the claims for these services were filed past the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the chiropractic services was not filed until May 15, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the chiropractic services coded as 98941 performed on October 
28, 2021, through December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gastrointestinal PCR Panel (87798 x13) provided May 
26, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you strongly believe that the denial of this 
claim based on the grounds of medical necessity is incorrect. The Plan denied your request. The Plan says this 
service is not deemed medically necessary by the Plan.  
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the denial of Gastrointestinal PCR Panel was appropriate 
based upon coding guidelines presented above and not on medical necessity. The review has determined that 
the items/services at issue in this case were not medically reasonable or 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the Gastrointestinal PCR Panel (87798 x13) provided May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair. 
 
You asked the Plan to pre-approve a lift chair. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 a lift chair have been met. Specifically, medical records were requested but not received. Medical necessity cannot be established without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve a lift chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hiatal hernia repair with LINX Reflux Management 
System (43284). 
 
You asked the Plan to pre-approve LINX Reflux Management System. You say that this service/procedure is 
medically necessary. The Plan denied your request. The Plan says this procedure/service is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that the LINX Reflux Management System is not considered reasonable and necessary for the diagnosis or treatment of an injury or disease. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage have not been met, as LINX Reflux Management System is not considered medically necessary and 
reasonable. Therefore, we decided that the Plan does not have to pre-approve hiatal hernia repair with LINX 
Reflux Management System (43284).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 15, 2022, and billed with codes 87640, 87481, 87798, 87653 and 81003. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on August 15, 2022, and billed with codes 87640, 87481, 87798, 87653 and 81003.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the pulmonary stress test, and the cessation 
counseling visit provided on June 21, 2023, by an OON provider.  
 You asked the Plan to pay for the office visit, stress test, and counseling visit. You say that you are appealing 
the denial with supporting documentation. The Plan denied your request. The Plan says these services are not 
covered when received by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also say that out-of-network outpatient diagnostic tests and physician 
services are not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit, the pulmonary stress test, and the 
cessation counseling visit provided on June 21, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on July 
10, 2023 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, and continuing until the 
COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get up to eight free over-
the-counter tests for the month of April any time before April 30th and can then get another set of eight free 
over-the-counter tests during each subsequent calendar month through the end of the COVID-19 PHE. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on July 10, 2023