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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require an IRF admission and close physician supervision. The Plan denied your request. The Plan says 
the enrollee's condition does not meet the Medicare rules for an IRF 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 procedure codes 85610-GZ and 85730-GZ billed for date of 
service December 7, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that services billed with the GZ modifier are automatically denied. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 85610-GZ and 85730-GZ billed for date of service 
December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services.  

You asked the Plan to pre-approve home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
reported to be non-ambulatory and is dependent for transfers and dependent for several activities of daily 
living. Given the therapy treatments already provided and the therapy recently approved by the health plan, the 
records do not support that the complexity of the enrollee's conditions are such that the skills of a professional 
therapist are required to achieve further improvement in the enrollee's symptoms or functional status.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on March 28, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total allowed amount for the prescription drugs is $355.76. You are 
being asked to pay $71.15 ($355.76 x 20% = $71.15). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from March 19, 2023, to March 
20, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says you billed this claim with an incorrect Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 indicates that the services were performed in an outpatient hospital setting.
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided from March 19, 2023, to March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the IRF admission for your physical 
therapy. Your physical therapist and occupational therapist feel you need this admission so that you can build 
up your strength before you begin chemotherapy. The Plan denied your request. The Plan says based on a 
careful review of your information, our medical team determined that it is not necessary for you to be admitted 
into an IRF at this time. 
 
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 you are medically stable and do not need a physical medicine and rehabilitation 
physician's supervision three times a week in an IRF. There are no rehabilitation nursing needs identified. At 
your current functional level, you do not need specialized and intensive therapies consisting of at least three 
hours of therapy per day at least five days a week with multidisciplinary approach in an IRF. The complexity of 
your medical, rehabilitation, and nursing needs (combined complexity) do not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in-home with services or in 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional 7 fractions, each, of computed tomography (CT) 
guidance, stereoscopic x-ray guidance, and intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve CT guidance, x-ray guidance, and IMRT. You say that these services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says that that they are not 
medically reasonable and necessary. 
 
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 CT guidance, x-ray guidance, and 
IMRT. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found that 35 fractions of IMRT would be within accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT guidance, x-ray guidance, and IMRT have been met. Therefore, we decided 
that the Plan has to pre-approve an additional 7 fractions, each, of computed tomography (CT) guidance, 
stereoscopic x-ray guidance, and intensity-modulated radiation therapy (IMRT).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798 and 
87801 billed for date of service January 12, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798 and 87801. You say that 
these services were necessary and are supported in the medical record. The Plan denied your request. The Plan 
says these services are not supported for separate reporting 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 CPT code. 
 
In this case, we have confirmed that code 87150 is a column II code to column I code 87500, and codes 87481, 
87641, 87653 and 87798 are each column II codes to column I code 87801. Codes 87481 and 87641 have not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met for codes 87481 and 87641. However, codes 87150, 87653 and 87798 were 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 87150, 87653, 87798 and 87801. Our 
reviewer says that these codes are not supported by the records provided. Our reviewer found that the records 
provided do not support that codes 87150, 87653 and 87798 were unusual non-overlapping services in this 
case. Therefore, the XU modifier is not supported with these codes and separate payment/reporting of these 
services is not appropriate. In addition, our reviewer found that there is no documentation in the medical record 
that the practitioner ordered infectious agent detection by nucleic acid by amplified probe technique, multiple 
organisms (87801) for 3 units. There is an order for a Urinary Tract Infection Panel with Antibiotic Resistance 
with no date entered by the practitioner and a printed name representing the practitioner that is not clearly the 
practitioners signature as required by Medicare rules. 
 
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 87150, 87481, 87641, 87653, 87798 and 87801 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 
87653, 87798 and 87801 billed for date of service January 12, 2023.
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 March 3, 
2022, to April 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim should be paid at the Medicare 
allowed amount. The Plan denied your request. The Plan says there are no records billed for the episode of 
care. 
 
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. 
 
We looked at the file and Medicare rules. In this case, there are no medical records provided to show that the 
billed services were supported. The file shows that the Plan made multiple attempts to obtain additional 
information with no success. Based on this information, we decided that the Medicare rules for coverage 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 March 3, 2022, to April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that hyperbaric oxygen therapy is medically 
necessary to prevent significant loss of tissue and for best overall patient outcomes. The Plan denied your 
request. The Plan says the patient does not meet criteria for HBO therapy because the records do not show that 
they have undergone at least 30 days of standard wound care without signs of hearing or that HBO therapy is 
being planned as an adjunct to standard wound care. 
 
The Plan follows Medicare rules. Medicare rules say that the use of hyperbaric oxygen therapy (HBO therapy) 
is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of 
treatment with standard wound therapy and must be used in addition to standard wound care. Failure to respond 
to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. 
Wounds must be evaluated at least every 30 days during administration of HBO therapy. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve HBO therapy. Our reviewer says that 
the requested HBO therapy does not meet Medicare's medical necessity criteria. Our physician reviewer found 
the enrollee had surgical wound dehiscence following breast reconstruction. She underwent bilateral 
mastectomy on July 26, 2023, with reconstruction and implant placement. She was evaluated on August 9, 
2023, for skin color changes following surgery, and her provider noted that she had a failed flap with duskiness 
and evidence of soft tissue necrosis. The wound measured 5.5 x 11 x0 cm. She was also educated on use of 
wound cleansing and dressing. The records do not show that the enrollee has undergone at least 30 days of 
standard wound care without signs of healing, or that HBO therapy is being planned as an adjunct to standard 
wound 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 21, 2022.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code ZBB9S coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that confirms this.
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 code. In this case the reported DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for February 14, 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 procedure code G0483 is not supported. 
 
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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no detailed 
physician order for 22 or more drug classes. 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 
procedure code G0483 billed for February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that while the provider did bill with valid DEX Z-Code ZB1CW, the procedure code 81479 billed was not listed as a recommended code. Per Local Coverage Determination (LCD) L35160 - MolDX: Molecular Diagnostic Tests - Payment Rules: MolDX will reimburse approved tests covered for dates of service consistent with the effective date of the coverage determination. Per Local Coverage Article (LCA) A57526 - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT): To report a Molecular Diagnostic Test service, please submit the following claim information: Select appropriate CPT code. Per the Palmetto GBA DEX Diagnostic Exchange Registry: Procedure code 81479 is not listed as a recommended code. Per these Medicare guidelines, the Plan has correctly denied the claim for payment as the provider did not bill with one of the recommended procedure codes for Z-code ZB1CW.
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 code. In this case, this claim could not be paid as this service was not billed with the appropriate code.
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 provided to the enrollee on July 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that the services requested 
are medically necessary. The Plan denied your request. The Plan says only the preferred brand products listed 
in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits.  
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a continuous glucose monitor (CGM). Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current setting. 
 
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 is improving but still requires acute care 
services before transitioning to a lower level of care. 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 they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.