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 needs to be monitored in a setting 
without going home. The Plan denied your request. The Plan says the request does not meet Medicare 
guidelines for medical necessity because the enrollee's medical condition requires further evaluation and 
treatment in the acute care hospital. 
 
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 was admitted for cirrhosis, ascites, cellulitis and a fall. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. 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 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. 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. 
 
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 testing provided on January 6, 2023. 
 
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 January 6, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the 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 that you do not have complex nursing or rehabilitation needs. 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. There is not a 
reasonable expectation that you 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  outpatient surgery with an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve  outpatient surgery with an OON provider. You say that the requested OON 
provider has the best qualified and trained staff for the needed procedure. You say that you want to receive the 
best results possible as it is your vision at risk.  The Plan denied your request. The Plan says there are 
contracted providers and facilities that can be utilized for the necessary procedure.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient surgery with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met.  Our physician 
reviewer found the Plan's denial is medically justified on the basis that there is adequate care at the in-network 
facility. The requested macular hole surgery is a standard retinal outpatient surgery that can receive adequate 
care at any facility that performs routine retinal surgeries. There is nothing unique about the enrollee's 
condition that would make it medically necessary to see the requested OON provider. The Plan has shown that 
they have in-network providers who meet the Standards of Care required for treatment of the enrollee's 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient surgery with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  outpatient surgery with an out-of-network (OON) provider.
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 medically 
necessary. The Plan denied your request. The Plan says the admission to a LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting. The 
documentation does not support that LTACH services are medically necessary 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 11, 2023, to 
March 12, 2023. 
 You asked the Plan to pay for the home health services. You say that a valid NOA was sent to the Plan. The 
Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied. The Plan says that although you contend that you submitted the NOA with your appeal, none was 
included. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA has not been received by the Plan. As a result, no payment can be made on this claim. 
Please do not send the NOA to Maximus.  Any further questions regarding submission of this NOA should be 
sent to the Plan directly. Therefore, we decided that the Plan does not have to pay for home health services 
provided from February 11, 2023, to March 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that you may have cancer and cannot start 
treatment until you have a release from the oral surgeon. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716 billed for date of service December 
15, 2022. 
 You asked the Plan to pay for procedure code 75716. The Plan denied your request. The Plan says payment for 
code 75716 is bundled into payment for code 37184. 
 
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 75716 
is a column II code to column I code 37184. 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 75716 billed for date of 
service December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49020 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 49020. The Plan denied your request. The Plan says payment for 
code 49020 is bundled into payment for code 43840. 
 
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 49020 
is a column II code to column I code 43840. 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 49020 billed for date of 
service November 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service March 9, 
2023.  
 
You asked the Plan to pay for procedure code 64488. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64488 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64488 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64488 billed for date of service March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on February 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81479) provided on February 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 9, 2023, billed with 
procedure code 77080. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis per 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors will pay claims for screening tests 
when coded with a valid diagnosis code indicating the reason for the test is postmenopausal female, vertebral 
fracture, hyperparathyroidism, or steroid therapy.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with diagnosis code 
Z13.820, which is not a valid diagnosis for the service provided. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on January 9, 2023, billed with procedure code 77080.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the chemotherapy regimen of cisplatin (J9060), gemcitabine 
(J9201), Fulphila (Q5108), Aloxi (J2469), and dexamethasone (J1100). 
 
You asked the Plan to pre-approve the chemotherapy regimen. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says that these drugs are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the chemotherapy regimen. Our 
reviewer says that the chemotherapy regimen is safe, effective, and medically reasonable and necessary for the 
enrollee. Our physician reviewer found that cisplatin and gemcitabine are frequently used chemotherapeutic 
regimens. A few studies have demonstrated the efficacy of cisplatin and gemcitabine combination for 
metastatic breast cancer after progression on an adriamycin and cyclophosphamide (AC) regimen. Fulphila, 
Aloxi, and dexamethasone are medications that complement the chemotherapy with treatment of the side 
effects. 
 
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 chemotherapy regimen have been met. Therefore, we decided that the Plan 
has to pre-approve the chemotherapy regimen of cisplatin (J9060), gemcitabine (J9201), Fulphila (Q5108), 
Aloxi (J2469), and dexamethasone (J1100).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72146 and 72148 billed for date of service 
December 2, 2022.  You asked the Plan to pay for procedure codes 72146 and 72148. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for both CPT codes 72146 and 72148 is 1. The MAI value for each of these codes is 3. 
You billed 2 units of both codes, exceeding the MUE. You did not provide all the required evidence showing 
that the excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 72146 and 72148 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 72146 and 72148 billed for 
date of service December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93296 provided on March 8, 2023. 
 
You asked the Plan to pay for procedure code 93296. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 93296 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 93296 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 93296 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 93296 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for procedure code 93296 provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage (T2002). 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee does not have the money to 
pay for transportation to this doctor's office. The Plan denied your request. The Plan says you are requesting an 
additional 8.2 miles for a total of 38.2 miles and your benefit only allows 30 miles. The Plan also says you have 
exceeded your benefit limit. 
 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 up to 30 one-way trips and each one-way trip must not exceed 30 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 30 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional transportation 
mileage (T2002).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2023, to March 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2023, to March 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 21, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 21, 2022.