Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 19, 
2023.  
 
You asked the Plan to pay for procedure code 99497. You say that the medical records show that advance care 
planning along with tobacco use counseling was performed. The Plan denied your request. The Plan says 
payment for code 99497 is bundled into payment for code 99291. 
 
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 99497 is a column two code to column one code 99291 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 99497 billed for date of service May 19, 2023.
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 need to be admitted to an IRF. The Plan denied 
your request. The Plan says your records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a lower level of care. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You do have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement; however, the documentation doesnt support that you meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain functional status. You can safely receive further services at 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mobile radiology services (74230, 70100, 99204, 72040) 
provided on April 11, 2023. 
 
You asked the Plan to pay for the mobile radiology 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 rules state that if a mobile unit is serving an 
entity for which another POS code already exists, providers should use the POS code for that entity. 
 
We looked at the file and Medicare rules. Place of Service 11 was billed, however records show this was 
provided in a mobile setting at a Skilled Nursing Facility. Based on this information, we decided that Medicare 
rules for coverage of the mobile radiology services have not been met. Therefore, we decided that the Plan does 
not have to pay for mobile radiology services (74230, 70100, 99204, 72040) provided on April 11, 2023.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
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 rehabilitation  hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain their functional status.  The enrollee can receive further services at 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 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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show the enrollee requires or can participate in 
intensive services consisting of 3 hours of daily therapies for your rehabilitation.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain the enrollee's functional status.  The enrollee can receive further services at 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 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: 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 appears to still be unstable and requires additional acute care hospital 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 13, 2023. 
 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 the claim was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code reflects the actual place where the 
beneficiary receives the face-to-face service and determines whether the facility or non-facility payment rate is 
paid.  
 
We looked at 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. The POS code 11 which was reported is not 
supported because the records clearly indicate that the services took place at a nursing home. There is no 
evidence that the services in dispute were performed in the office setting. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99214) 
rendered on March 13, 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 the documentation received only shows bilateral injections were completed. 
 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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
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 services documented were not 
supported as being separately identifiable from the injection given. The evaluation described pain in the right 
knee, for which the injection was given. 
 
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 evaluation and management services (procedure code 99214) rendered on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on September 27, 2022. 
 
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 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing (87481,87798, 87801) provided 
July 6, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says The PCR testing is 
considered unproven and 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 looked at  the file, and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. 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 Urine PCR panel testing (87481,87798, 87801) provided July 6, 2021.
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 admission is medically necessary for the enrollee. 
The Plan says services may be provided at a lower level of care. The Plan denied your request. The Plan says 
the enrollee's condition does not meet all of the requirements for inpatient rehabilitation admission. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical conditions appear improved on stable medications with no issues that appear to require a physicians 
evaluation three or more times per week in a hospital setting. The enrollee does require physical therapy and 
occupational therapy services, but the medical records provided do not clarify why the enrollee requires an 
intensive inpatient rehabilitation therapy program. Provided medical records do not support that the intensive 
inpatient rehabilitation therapy program is necessary and that therapy at a lower level of care such as in a 
skilled nursing facility is not appropriate for the enrollee. Based on the medical records provided, the enrollee 
would be expected to participate in and benefit from the intensive rehabilitation therapy program provided in 
an inpatient rehabilitation facility; however, the medical records do not support a complexity of needs which 
requires an acute inpatient rehabilitation facility over a skilled nursing 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on July 18, 2023, July 19, 
2023, and July 20, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
code 99233 provided on July 18, 19, and 20, 2023. The Plan denied your request. The Plan says the medical 
records do not support the billing of code 99233 provided on July 18, 19, and 20, 2023. 
 
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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded.  
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 99233. Our reviewer says that the medical 
records do not support the billing of code 99233 provided on July 18, 19, and 20, 2023. Our reviewer found the 
medical records do not support that a high level of medical decision making was made for the dates of service 
at issue. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on July 18, 2023, July 19, 2023, and July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on October 7, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says 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 does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on October 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided the Plan does not have to pay for physician services billed to the enrollee for October 10, 2022.

You asked the Plan to pay for this claim as billed. You say that these services were necessary. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial
for insufficient denial information in the case file. The Plan requested a reopen and provided additional
information. The Plan noted that this claim denied because this provider was not eligible to be paid for this
procedure or service. The rendering provider is an individual physician and cannot bill for Opioid Treatment
Program Services separately. The provider is not billing under the facility; they are billing as an individual
physician.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, individual providers cannot bill for this service as payment for this type
of service is included in the facility claim.

Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does
not have to pay for physician services billed to the enrollee for October 10, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this injection helps and you cannot take non-steroidal 
anti-inflammatory drugs. The Plan denied your request. The Plan says that repeat administration of Zilretta in 
the same knee has not been shown to be safe and effective. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Zilretta. Our reviewer says that you 
meet criteria for this use of Zilretta. Our physician reviewer found the record indicates that you have a 
diagnosis of osteoarthritis of the knee and have had efficacy from previous administration of the requested 
drug. The Food and Drug Administration (FDA) has stated that Zilretta is indicated as an intraarticular 
injection for treatment of osteoarthritis-related knee pain. The Medicare compendia do not contain a prohibition 
on repeat administration of the requested drug. The record provided is sufficient to establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are satisfied. The requested service 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
use of Zilretta.  
 
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.