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

 
We decided that the Plan does not have to pay for procedure codes 94760 and 99285 billed for date of service 
August 12, 2022.  
 You asked the Plan to pay for the billed services. You say that the documentation supports the level of service. 
The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 99285 and 94760 are not supported in the medical record. Specifically, the records 
provided do not include the date of service at issue. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 94760 and 99285 billed for date of service August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a platelet rich plasma injection provided on May 11, 2022. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says a platelet rich plasma 
injection is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are not covered.  
 
We looked at the file and Medicare rules. The record shows the injection was requested to treat a joint 
condition. Based on this information, we decided that Medicare rules for coverage of the injection have not 
been met. Therefore, we decided that the Plan does not have to pay for a platelet rich plasma injection provided 
on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test provided on January 24, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that the DecisionDx-SCC test was medically 
necessary. The Plan denied your request. The Plan says the DecisionDx-SCC test is experimental.  
 
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 pay for the DecisionDx-SCC test. Our reviewer says 
that the requested DecisionDx-SCC test is not considered medically reasonable and necessary. Our physician reviewer found that the use of molecular profiling to determine treatment of cutaneous squamous 
cell carcinoma is not considered a standard of care. Use is not supported by the NCCN Guidelines or the 
medical literature. The service is not reasonable or 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 DecisionDx-SCC test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SCC test provided on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the enrollee is in need of high frequency chest 
wall oscillation therapy. The enrollee has tried Capella flutter and that did not help to mobilize. The Plan 
denied your request. The Plan says the request is not medically necessary because your records show you do 
not have bronchiectasis or a qualifying neuromuscular disease. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found provided records in this case do not document 
a diagnosis of cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency 
chest wall oscillation device may be covered. Records do not document paralysis of the diaphragm. Provided 
records in this case do not document the enrollee presently uses a mechanical in-exsufflation device (E0482) 
and plans to continue to do so. Provided records document trial and failure of an Acapella flutter valve as well 
as nebulizers. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep as an outpatient. The records do not show that this has been 
tried and failed. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204 for date of service February 2, 2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that this code is included in codes 95911 and 95886 
 
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. In this case, the Plan states that code 99204 is a column II code to column I 
codes 95911 and 95886. We have confirmed that code 99204 is not a column II code to column I codes 95911 
and 95886. This means the Plans argument for non-coverage is invalid. No other denial rationale was 
provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for 
procedure code 99204 for date of service February 2, 2023.  
 
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 pre-approve a power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a POV. The Plan denied your request. The Plan says there is no evidence 
that a POV is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 POV. Our reviewer says that a POV is 
not medically reasonable and necessary for you. Our physician reviewer found you can independently perform 
transfers, daily activities and ambulate household distances with the assistance of a cane. You have a rollator 
and manual wheelchair for community mobility as well as personal care assistance hours allotted for shopping 
and transportation. Our reviewer found that a power mobility device or scooter would not significantly improve 
your level of independence with mobility and is primarily convenience in nature. Our physician reviewer also 
found that there is also no indication that you can safely operate a power mobility device. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV) (K0800).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided on December 30, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the billed code is not separately payable. 
 
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 CPT code 99284 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of procedure code 12001, which was billed for the same date of service. Based on this 
information, we decided that Medicare rules for coverage of the emergency room services have not been met. 
Therefore, we decided that the Plan does not have to pay for emergency room services (99284) provided on 
December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of June 26, 2023. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee can be safely treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet criteria for continued inpatient psychiatric care. Our physician reviewer 
found it is not expected that the enrollee will improve in a reasonable period of time beyond the date in 
question as the enrollee is not showing any dangerousness to self or others, auditory or visual hallucinations, or 
aggressive behaviors while not showing any acute threats to safety. It does not appear medically reasonable and 
necessary to have psychiatric care provided at the acute inpatient level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care as of June 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 1, 2022, to 
March 30, 2022. 
 You asked the Plan to pay for the home health services. You say that these services do not require prior 
authorization. The Plan denied your request. The Plan says you have failed to submit the required NOA.  
 
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, there is no evidence that you have supplied the required NOA for this claim.  As a result, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided from March 1, 2022, to March 30, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF admission was medically necessary. The Plan denied your request. The Plan says the Medicare criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that at the time of the appeal, the medical records show your needs were custodial in nature.
The Plan is correct in this case. 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. The medical records show that at the time of the appeal, the recommendation by physical therapy was for discharge home with assistance from family or home health. The medical records do not show the enrollee required an inpatient SNF level of nursing or therapy care 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 skilled nursing facility (SNF) care for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 1, 2023, to 
January 6, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that medical 
records were provided to support payment at the original DRG billed. The Plan denied your request. The Plan 
says the billed principal diagnosis code A41.9 (Sepsis Unspecified Organism) is not supported by the medical 
record. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9 (Sepsis Unspecified 
Organism). 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the principal diagnosis code A41.9 (Sepsis Unspecified 
Organism) is not supported by the medical record. Our physician reviewer found the member is a 93-year-old 
female with a past medical history including hypertension, and dementia who was admitted to the hospital with 
a diagnosis of pneumonia. The documentation indicates that after treatment in the emergency department, the 
member improved and was hemodynamically stable at the time of admission. The member was at her baseline 
mental status. There is no indication that the member had any significant organ dysfunction. Laboratory studies 
were not significant for sepsis. There was no evidence of life-threatening organ dysfunction due to 
dysregulated host response to an infection or persistent hemodynamic instability.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 1, 2023, to January 6, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has post Covid syndrome, 
chronic hypoxemic respiratory failure, and mild obstructive lung disease. Due to these diagnoses, the order for 
2-5L oxidizer pendant with activity and provider portable D size tank are medically necessary. The Plan denied 
your request. The Plan says the records do not show that the enrollee has been considered for, or failed 
treatment with, positive airway pressure (a device that keeps the airways open using mild pressure, for example 
CPAP and bi-level PAP). Additionally, to be reasonable and necessary, an item or service must not be 
investigational or experimental. 
 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with CPAP or BiPAP machine with AVAPS capability and failure of 
such a device has not been documented. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 12, 2022, to 
June 10, 2022. 
 You asked the Plan to pay for the home health services. You say that all services on the claim are valid and 
billable. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
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 start of care date is January 12, 2022. The NOA was not received by the Plan until July 6, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from May 12, 2022, to June 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 22, 2022, to 
September 20, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should be partially paid.  The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
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 start of care date is August 22, 2022. The NOA was not received by the Plan until October 14, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from August 22, 2022, to September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 5, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 8, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 8, 
2021.