Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pacemaker. 
 
You asked the Plan to pre-approve pacemaker. You say that the enrollee is having pauses. The Plan denied 
your request. The Plan says the records do not show that the enrollee has symptomatic bradycardia or 
symptomatic pauses. 
 
The Plan follows Medicare rules. Medicare rules state that pacemakers may be covered for specified 
conditions. 
 
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 pacemaker. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found while the enrollee has a history 
of paroxysmal atrial fibrillation with an asymptomatic conversion pause, there is no documentation of 
symptomatic bradycardia. As such, there is insufficient documentation to support the medical necessity for insertion of a pacemaker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pacemaker.
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 the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute in-patient care and 
is currently unstable for transfer to an LTACH. 
 
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 be improving somewhat with the current treatment; however, 
she is still unstable for transfer and requires additional acute care services that can safely be provided at the 
current facility. 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491 and 87640 provided on May 12, 
2023. 
 
You asked the Plan to pay for procedure codes 87491 and 87640. You say that the medical records support the 
billing of procedure codes 87491 and 87640. The Plan denied your request. The Plan says the medical records 
do not support the billing of procedure codes 87491 and 87640. 
 
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 87640 is Infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, amplified probe technique. 
 
Additionally, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 codes 87491 and 87640. Our reviewer says that 
the medical records do not support the billing of procedure codes 87491 and 87640. Our reviewer found 
procedure code 87491 is not supported. The records do not contain a test result for chlamydia trachomatis. It 
cannot be verified that this test was performed. 
 
Procedure code 87640 is not supported as a separate and distinct procedure from 87641. Based on the medical 
records, this is included in 87641 and should not be reported separately. 
 
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 codes 87491 and 87640 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87491 and 87640 provided on May 12, 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 IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not medically necessary.  
 
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 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 medical records do not support that 
the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility.  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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
abdomen and pelvis. 
 
You asked the Plan to pre-approve a CTA of the abdomen and pelvis. You say that the enrollee is not a 
candidate for other treatments. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA of the abdomen and pelvis. Our 
reviewer says that the requested CTA is not medically necessary. Our physician reviewer found current 
guidelines do not support regular use of this procedure for benign prostatic hypertrophy, and literature does not 
provide sufficient high-quality evidence to sufficiently support this procedure for this condition at this time.  
 
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 CTA of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen and 
pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service March 15, 
2023. 
 
You asked the Plan to pay for procedure code G0453. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says payment for code G0453 is 
bundled into payment for code 95829. 
 
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 G0453 
is a column II code to column I code 95829. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0453 billed for date of service March 15, 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 the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the enrollee does not meet all the requirements for admission to an LTACH.  
 
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 that the enrollee is receiving acute hospital care, and acute care services have not 
been denied. There are no required medical services identified that are available at the LTACH that are not available at the current health care setting being offered by the Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
Additionally, the documentation does not support that an additional 25 days of hospitalization are reasonably 
expected for the enrollee in this case. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 provided on January 30, 2023. 
 
You asked the Plan to pay for procedure code 87506. You say that the medical records support the billing of 
code 87506.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 87506.  
 
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 87506 is Infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
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 87506. Our reviewer says that the medical 
records do not support the billing of code 87506.  Our reviewer found the record shows more than 11 targets 
were tested for. There is a more specific code for the number of targets tested. 
 
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 87506 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87506 provided on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for out of network lab services provided to the enrollee on July 18,
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 the enrollee did not have prior authorization for out of network care. Maximus
overturned the Plans denial because a Plan contract was not submitted. The Plan requested a reopen and
provided the required Plan contract.
The Plan is correct in this case. 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 in this case is not a network provider with the Plan. The ordering physician was not a network
provider. The Plan had network providers available who could have provided the services at issue in this
appeal. The Plan did not pre-approve the service 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 out of network lab
services provided to the enrollee on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis; 
up to 1 hour (96365) and intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour 
(96366) provided on April 25, 2023. 
 
You asked the Plan to pay for intravenous infusion. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says codes 96365 and 96366 
remain not supported. There are more appropriate codes that should be used for the service provided. 
 
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 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 intravenous infusion. Our reviewer says that the services do 
not meet criteria for approval of payment on this claim. Our reviewer found that code 96365 and code 96365, 
the medical record describes intravenous insulin treatment provided for an outpatient on April 25, 2023. In this 
case, there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code that should be 
reported for the services 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 intravenous infusion have not been met. Therefore, we decided that the Plan 
does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis; up to 1 hour (96365) and 
intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour (96366) provided on April 25, 
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 the enrollee meets the full criteria for an IRF stay. 
You are requesting IRF services instead of a lower level of care as the enrollee has rehabilitation goals that 
include returning to their prior level of function with assistance/care. You also say admission to the IRF is 
required as the enrollee's current needs cannot safely be met at a lower level of care. The Plan denied your 
request. The Plan says admission to an IRF is not medically necessary.  
 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.? There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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 the LTACH level of care is most 
appropriate for the enrollee to achieve the best outcome due to his complex medical needs. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for a 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 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 appropriate care in the current acute care setting as provided 
by the plan. Given there are offered alternatives, a LTACH admission is 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 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: Favorable

 
We decided that the Plan has to pre-approve a referral to a dermatologist. 
 
You asked the Plan to pre-approve a referral to a dermatologist. You say that the requested referral to a 
dermatologist for a second opinion is medically necessary. The Plan denied your request. The Plan says that the 
requested referral to a dermatologist for a second opinion is not medically necessary as the enrollee can receive 
treatment with her new primary care provider (PCP).  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 referral to a dermatologist. Our 
reviewer says that the requested referral to a dermatologist for a second opinion is medically necessary. Our 
physician reviewer found to rule out other causes of "sores", such as infection or autoimmunity, a referral to a 
dermatologist for a second opinion is medically appropriate in this case. 
 
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 referral to a dermatologist have been met. Therefore, we decided that the Plan 
has to pre-approve a referral to a dermatologist.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for 
multiple therapies. Additionally, there a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for visual field testing (92083) provided on July 6, 2023.

You asked the Plan to pay for the visual field testing. You say that this service was medically necessary. The Plan denied your request. The Plan says this service was not billed with a covered diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that visual field testing to be covered, the submitted medical record must support the use of the selected codes. The submitted codes must describe the service performed.

We looked at the file and Medicare rules. Diagnosis code Z02: Encounter for examination for driving license is not listed as a code that supports medical necessity for this service, per Local Coverage Article: Billing and Coding: Visual Field Examination (A57637). Based on this information, we decided that Medicare rules for coverage of the visual field testing have not been met. Therefore, we decided that the Plan does not have to pay for visual field testing (92083) provided on July 6, 2023.