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 December 9, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from December 9, 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 
December 9, 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 December 9, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 9, 
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 December 9, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 9, 
2023, forward.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service February 22, 
2023, to March 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that you are not required to submit a notice of 
admissions. The Plan denied your request. The Plan says an NOA is required. The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services.  
 
We looked at the file and the rules. The file does not show that an NOA was not submitted as required. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health care billed for dates of service 
February 22, 2023, to March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 21, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. 
There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. 
As such, a single code with one unit of service should be used. 
 
The CPT Code Manual definition of code G0452 is molecular pathology procedure; physician interpretation 
and report. We find that G0452 is not supported in the medical record. The records do not include a physician 
interpretation and report. Based on this information, we decided that Medicare rules for coverage of the testing 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for 
date of service February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve azelastine and fluticasone combination nasal spray. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve azelastine and fluticasone 
combination nasal spray.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablet. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the record does not show this is being used to treat nausea 
associated with chemotherapy. The Plan also says that the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablet.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DaTscan (78803).  
 
You asked the Plan to pre-approve the diagnostic service. You say that this is necessary to determine whether 
the enrollee has evidence for neurodegeneration causing their subtle symptoms. You also say that this would 
provide diagnostic clarity and guide medical management. The Plan denied your request. The Plan says this is 
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 the diagnostic service. Our reviewer 
says that the requested DaTscan is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records in this case do not document how the test results would be used 
in the management of the patient at this time. Therefore, the reviewer found that the requested DaTscan is 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 diagnostic service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a DaTscan (78803).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory panel testing provided on August 7, 2023. 
 
You asked the Plan to pay for lab panel. You say that this claim was not processed according to Medicare 
guidelines. The Plan denied your request. The Plan says this claim was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular syndromic panels for infectious 
disease pathogen identification testing must be billed with certain claim information, including a single unit of 
service of either a proprietary panel code or code 87999.   
 
We looked at the file and Medicare rules. This panel testing was not billed with a single unit of service of the 
appropriate procedure code. Based on this information, we decided that Medicare rules for coverage of lab 
panel have not been met. Therefore, we decided that the Plan does not have to pay for laboratory panel testing 
provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 7, 2023, billed with 
procedure code 99213-24. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan follows Medicare rules. Medicare rules say that many services within the postoperative period are 
considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We asked our coding 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 practitioner services provided. Our 
reviewer says that documentation does not support the billed code. Our physician reviewer found that the 
medical record describes a post operative evaluation and management service for follow up of the right 
hip.  Patient had surgery on May 12, 2023. In this case, an unrelated service was not found in medical record 
and therefore 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 the practitioner services provided. have not been met. Therefore, we decided 
that the Plan does not have to pay for practitioner services provided on July 7, 2023, billed with procedure code 
99213-24.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abrysvo. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Abrysvo.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 400 units of procedure J1575 rendered from June 5, 2023, to 
June 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code J1575-JB (400 units) remains not 
supported, as the records do not support the amount of units 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.  
In this case, the CPT Code Manual definition of code J1575 is "Injection, immune globulin/hyaluronidase, 
(hyqvia), 100 mg immuneglobulin." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the record does not support 100 
units of J1575. The documentation does not specify this amount of J1575 was provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for 400 units of procedure J1575 rendered from June 5, 2023, to June 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility.  
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 enrollee is receiving acute hospital care, and acute care services have not been 
denied. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. 
 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee is medically stable and will 
benefit to transfer to an LTACH. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable with the current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current treatment 
facility until more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH is not medically necessary as it would not be clinically advantages. Completion of treatment at the 
current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for upgraded electronics and a footplate extension
for a Group 3 Power wheelchair being provided to the enrollee.

You asked the Plan to provide coverage for the upgraded electronics and footplate extension. You say that at
the time of the appeal, the requested wheelchair accessories were medically necessary. The Plan denied your
request. The Plan says the required Medicare criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted
that the requested upgraded electronics (E2377, E2313, and E2311) can be burdensome for enrollee's who do
not require a joystick. The Plan states the medical records show the enrollee's limb strength and function are
adequate to control the standard power options and switches that already come with the approved power
wheelchair. The Plan notes both Maximus and the Plan agree the footplate extension is not covered by
Medicare as this is a convenience item.

The Plan is correct in this case. 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. The medical records in the case file does not
support that the requested upgraded electronics and extended footplate extension were medically reasonable
and necessary for the enrollee in this case at the time of the appeal. There is no documentation of the medical
necessity of controlling the power options through a joystick and the footplate extension is not covered by
Medicare. Therefore, we decided that the Plan does not have to provide coverage for upgraded electronics and
a footplate extension to be provided for an approved Group 3 Power wheelchair for the enrollee.
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 requires physical therapy to assist in 
regaining strength and mobility to return to baseline and function of normal daily activity. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on August 14, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on August 
14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says the enrollee has not tried evidence-based psychotherapy for 
depression. 
 
The Plan follows Medicare rules. Medicare rules say that TMS therapy not ordered by and furnished under 
direct supervision, by a psychiatrist will be considered not medically reasonable and necessary and not subject 
to coverage. 
 
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 TMS. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found this enrollee clearly does not meet the clinical 
criteria for the use of transcranial magnetic stimulation therapy utilizing LCD (L36469) as the enrollees record 
shows no documentation of the enrollee undergoing psychotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcranial magnetic stimulation (TMS).