Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the request is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that the documentation does not support that the complexity of the enrollee's nursing,
medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care, requiring treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program at least 3 hours a day for 5 days a week, or 15 hours
over 7 consecutive days. It is not documented that there was a reasonable expectation that the enrollee would
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine examination, progressive lens, premium, high index, 
and fundus photography interpretation and report provided on March 18, 2023. 
 
You asked the Plan to pay for routine examination, progressive lens, premium, high index, and fundus 
photography interpretation and report. You say that you went to this provider. You also say that you looked on 
the insurance information and they accepted your insurance. The Plan denied your request. The Plan says 
routine eye examinations and eyewear must be obtained from a provider in the Plan's vision vendor network. 
The Plan also says that services obtained from vendors outside this network are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when The Plan rules say routine eye examinations and eyewear must 
be obtained from a provider in the Plan's vision vendor network. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-Medicare covered routine eye exams and 
eyewear must be obtained from a provider in the Plan's vision vendor network. The Plan contract also says that 
services obtained from vendors outside this network are not covered. The record shows the provider is not in-
network.  Based on this information, we decided that the Plan's rules for coverage of routine examination, 
progressive lens, premium, high index, and fundus photography interpretation and report have not been met. 
Therefore, we decided that the Plan does not have to pay for routine examination, progressive lens, premium, 
high index, and fundus photography interpretation and report provided on March 18, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services billed (87481, 87798, 87801, and 87150) to the enrollee for December 16, 2022.
You asked the Plan to pay for these services . You say that this claim should be paid. The Plan denied your request. The Plan says these services were billing incorrectly. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that billed codes 87150-59 X 12,87798-59 X 13,87481-59 X 4,87801-59 X 2,87640-59, and 87653-59. The Plan notes 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. This is called stacking codes and is not acceptable.
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 codes. In this case, this claim could not be paid as billed as these codes cannot be billed separately for this type of service.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services billed (87481, 87798, 87801, and 87150) to the enrollee for December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planning (D4341) on teeth #'s 1, 8, 25 and 32 and a complete series of x-rays (D0210) provided on May 20, 2022.
You asked the Plan to pay for the dental services. You say that your provider told you these services would be covered under your dental plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional documentation.
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 benefit for the periodontal scaling and root planning was exhausted on date of service December 10, 2020 and the benefit for the complete series of x-rays was exhausted on date of service November 24, 2020. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planning (D4341) on teeth #'s 1, 8, 25 and 32 and a complete series of x-rays (D0210) provided on May 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal as the 
enrollee meets the full criteria for an IRF stay. The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a parathyroid planar imaging (78070). 
 
You asked the Plan to pre-approve a parathyroid planar imaging. You say that this nuclear test is needed to 
confirm so treatment can begin. The Plan denied your request. The Plan says this request does not meet the 
Medicare or health plan coverage criteria. 
 
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 a parathyroid planar imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no laboratory data suggestive of elevated parathyroid hormone or 
serum calcium level is provided. No vitamin D levels, or 24-hour urinary calcium level is available. Our 
reviewer found that the enrollee is noted to have underlying chronic kidney disease, which can cause secondary 
hyperparathyroidism. Work up for primary hyperparathyroidism is incomplete. Our physician reviewer also 
found that there is no clinical rationale for parathyroid imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a parathyroid planar imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a parathyroid planar imaging (78070).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 29. 2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that this was coded correctly based on the care 
rendered. The Plan denied your request. The Plan says the decision making was not highly complex to warrant 
use of code 99285. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 ED services as billed. Our reviewer says 
that the records do not support the code reported for these services. Our reviewer found the documentation 
describes the enrollee with neck and chest pain for 2 weeks. Physical findings revealed chest wall tenderness 
and neck tenderness. Vitals were stable. Workup was otherwise negative. She was diagnosed with 
musculoskeletal pain and given Toradol. The documentation did not sufficiently include medical decision-
making of high complexity. Therefore, the code, 99285, was not supported for this encounter.  
 
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 ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on December 29. 2022, billed with 
code 99285.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on September 6, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment cannot be 
made for these services. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20694. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgery 
services provided on September 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (0117U) provided on November 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this code is not covered 
according to Local Coverage Article A58801. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the rule used by the Plan does not apply to the state where this test 
was performed. The Plan has not provided a relevant citation with jurisdiction in this case. Therefore, we 
decided that the Plan has to pay for laboratory services (0117U) provided on November 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on June 27, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that these services do not require authorization. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care supplies 
provided on June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will be on intravenous antibiotics for 
several weeks, and the best place to regain function is in rehabilitation with three hours minimum of therapy a 
day. You say the enrollee came into the emergency room with a lot of pain and loss of function. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 3, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 16, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the test is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that next-generation sequencing (NGS) testing is 
covered when the test is approved by the Food and Drug Administration (FDA). 
 
We looked at the file and Medicare rules. The file shows that the test was not FDA-approved. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on January 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be safely discharged until their 
pressure ulcer is healed. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 27, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
January 27, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335 and 81479.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides. 
 
You asked the Plan to pre-approve additional rides. You say that you feel that you need these additional rides 
due to multiple health issues. The Plan denied your request. The Plan says you have used 12 one-way trips. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 12 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional rides.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99232 billed for date of service January 25, 2022. 
 
You asked the Plan to pay for code 99232. You say that this diagnosis code does not require a specific 
diagnosis to be billed as primary. The Plan denied your request. The Plan says you billed this claim with an 
inappropriate pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of R06.00 and J96.01. Code J96.01 is an Excludes1 code 
under code R06.00, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99232 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99232 billed for date of service January 25, 2022.