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

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87086, 87186, 
87481, 87500, 87556, 87563, 87640, 87651, 87653, and 87798 for date of service March 9, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87086, 87186, 87481, 87500, 87556, 
87563, 87640, 87651, 87653, and 87798 . You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together.  
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that N30.80 has an Excludes1 note in relation to N39.0. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the laboratory services billed with codes 87086, 87186, 87481, 87500, 87556, 87563, 87640, 
87651, 87653, and 87798  have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with codes 87086, 87186, 87481, 87500, 87556, 87563, 87640, 87651, 87653, and 
87798 for date of service March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that because the enrollee's tremors prevent them from 
using a glucose device. The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was met. Our physician reviewer found that the enrollee is on a medication that can 
cause low blood sugars. The enrollee is unable to reliably use a lancet device due to their tremor. Hence it 
appears reasonable to approve the CGM 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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
  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 imaging services provided on May 16, 2023, billed with 
procedure code 72072-26.  
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 72072-26 is Radiologic examination, spine; thoracic, 3 
views. 
 
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 the imaging services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the medical documentation supports 
another procedure code, there were only 2 views taken of the thoracic spine. As such, procedure code 72072-26 
cannot be verified. 
 
We looked at this coder's review, 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. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on May 16, 2023, billed with procedure code 
72072-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says a genicular nerve block is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to repay the recoupment of vision services provided on November 15, 2022.

You asked the Plan to repay the recoupment for vision services provided on November 15, 2022. The Plan
denied your request. The Plan says they were only responsible for up to $100 of the cost of these services per
the Plan contract. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus
did not apply the correct criteria.

The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services.
However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason,
the Plan's coverage rules apply in this case. The Plan covers up to $100 of the cost of these services. Any
amount over the $100 benefit is the enrollee's financial responsibility. Therefore, we decided that the Plan does
not have to repay the recoupment of vision services provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you require the injection to relieve 
your knee pain. The Plan denied your request. The Plan says the requested procedure is not medically 
necessary and reasonable. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered an experimental procedure. Therefore, the 
request is deemed not medically reasonable and 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestlye Libre 3. 
 
You asked the Plan to pre-approve a replacement continuous glucose monitor (CGM). You say that because 
your old CGM is not compatible to your cell phone, and you cannot measure your blood. The Plan denied your 
request. The Plan says the denial of authorization for the CGM is correct, because the clinical records did not 
indicate that the enrollee's current CGM was defective or broken. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment. 
 
  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 replacement continuous glucose 
monitor (CGM). Our reviewer says that the replacement criteria for a CGM was not met. Our physician 
reviewer found that it does not appear that the Freestyle Libre 2 system is not working from the records 
provided. Hence, a Freestlye Libre 3 coverage criteria are not met. 
 
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 replacement continuous glucose monitor (CGM) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestlye Libre 3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 31, 2023, billed with 
procedure code 99349-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We asked our coding 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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our physician reviewer found that the 
medical record describes wound assessment and wound care. However, does not include documentation of 
significant, separately identifiable evaluation and management (E/M) service above and beyond that associated 
with the wound care provided. As such, the billed code cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 31, 2023, billed with procedure code 
99349-25.
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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an 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 that there is no documentation provided indicating that the enrollee has medical 
necessity for an admission to an LTACH. The enrollee is receiving appropriate care at the present acute care 
facility. There does appear to be reasonable participation in therapy however, the enrollee does not have active 
medical conditions that would require treatment only in an LTACH and not in a lower level of care. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 pre-approve 5 home health physical therapy visits and 10 home 
health occupational therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are 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 
documentation does not support that the enrollee requires additional skilled nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to 
improve the enrollees condition, perform a maintenance program to maintain the enrollees condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 home health physical therapy visits and 10 home health occupational therapy 
visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 units of code 87798 billed for date of service June 19, 
2023. 
 
You asked the Plan to pay for 13 units of code 87798. The Plan denied your request. The Plan says the billed 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 13 units of code 87798 Our reviewer says 
that the records do not support 13 units of code 87798. Our physician reviewer found that the record does not 
specify which not otherwise specified infectious agents were tested for, and therefore, it cannot be verified that 
13 units were performed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 13 units of code 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for 13 units of code 87798 billed for date of service June 19, 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 needs IRF services as his goal is to 
return to his prior level of function. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements 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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute 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, 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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Eylea. 
 You asked the Plan to pre-approve Eylea. You say that the requested drug is necessary for the enrollee's 
condition.  The Plan denied your request. The Plan says the enrollee has not tried or failed the preferred drug in 
Byooviz before the requested drug. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that the 
enrollee does not meet the criteria for Eylea. Our physician reviewer found the documentation does not show 
the enrollee has tried and/or failed the required drug, Byooviz, to qualify for the use of Eylea.  The 
documentation also does not support that Byooviz would likely be less effective, and/or would likely have 
adverse effects 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the use of Eylea.
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 has recently experienced a significant 
decline in functional ability. You also say that the clinical notes demonstrate the enrollee's struggles with bed 
mobility, transfers, ambulation, and general activities of daily living. The Plan denied your request. The Plan 
says based on the available information, admission to IRF is not reasonable and necessary, as the enrollee's 
condition does not meet the Medicare rules.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a past medical history of atrial flutter, prostate cancer (2006) and hyperlipidemia and is living at home with 
weakness and functional decline. 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 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.