Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. 
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and cone beam CT capture and interpretation with field of view of both jaws; with or without cranium 
(D0367) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to an in-network provider; therefore, 
these services should be covered. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
  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. This benefit includes the 
requested oral evaluation - new or established patient (D0150) but is limited to one procedure every three plan 
years. Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium 
(D0367) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0367 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone beam CT 
capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided on 
December 13, 2022. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered comprehensive 
oral evaluation - new or established patient (D0150) on May 10, 2022. Therefore, this benefit was exhausted as 
of December 13, 2022. Therefore, we decided that the Plan does not have to pay for comprehensive oral 
evaluation - new or established patient (D0150) provided on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
October 31, 2022, to November 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of the inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 31, 2022, to  
November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. The Plan denied your request. The Plan says that 
the cost of the repairs exceeds the cost of a replacement wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the excess. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power wheelchair repairs have not been met. Specifically, the record shows that the cost of the 
repairs exceeds the cost of a replacement power wheelchair. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair repairs.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs was approved by the 
Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient 
management. As a result, at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in this enrollees clinical management.  
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a CardioMEMs Heart Failure (HF) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown-full cast high noble metal (D6792), a 
pontic-cast high noble metal (D6210), and a retainer crown-porcelain fused to noble metal (D6752). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollee's benefit for the requested items has 
already been exhausted.  
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollees benefit for the requested items has been exhausted. Specifically, the Plan contract provides 
coverage for one retainer crown and one pontic every five calendar years. The Plan previously issued approval 
for a retainer crown for teeth number 18 and 20 and a pontic for tooth number 19 for the enrollee. Therefore, 
the enrollee has exhausted the allowable benefit for the requested items in this case. Therefore, we decided that 
the Plan does not have to pre-approve a retainer crown-full cast high noble metal (D6792), a pontic-cast high 
noble metal (D6210), and a retainer crown-porcelain fused to noble metal (D6752).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the all lower extremity prostheses, flex-walk system or 
equal (L5981) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968).  

You asked the Plan to pre-approve the advanced foot and ankle. You say that you are replacing the same type 
of foot the enrollee presently wears to perform their activities of daily living. Please read over all of the 
evaluations and notes. The Plan denied your request. The Plan says the request for prosthesis with K3 foot does 
not meet Medicare criteria as reasonable and necessary. the requested prosthesis exceeds the enrollee's needs. 
 
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 the advanced foot and ankle. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the certified prosthetist/orthotist (CPO) states that the enrollee is at least a 
K3 ambulator, but this is not corroborated by the treating medical physician records as per Medicare 
guidelines. The prosthetist is the vendor. The physician documentation does not discuss the enrollee's 
ambulatory level or support the prosthetist's claims of the enrollee's need for the requested items. 
 
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 advanced foot and ankle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the all lower extremity prostheses, flex-walk system or equal (L5981) and 
addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that Maximus review states that "The file shows the Plan denied payment as there is a modifier indicator of 0 between code 80051 and the denied codes 82435, 84132, and 84295. We find that codes 82435, 84132, and 84295 do not have a modifier indicator of 0 when billed with code 80051".
However, the Plan notes the statement "The file shows the Plan denied payment as there is a modifier indicator of 0 between code 80051 and the denied codes 82435, 84132, and 84295" is incorrect. The Narrative Justification of the case file states "This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit." A review of the claim shows that no modifiers were billed for 82435, 84132, or 84295. As such, the codes were correctly denied.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to the omission of a required modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that the documentation shows medical necessity. 
The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 2, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee needs additional physical 
therapy to help with their leg pain. The Plan denied your request. The Plan says 4 additional physical therapy 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has chronic back problems and has made 
modest progress despite a full physical therapy course. The enrollee requires a repetitive exercise program and 
can continue at home. Therefore, continued input from a skilled therapist is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 4, 2022, billed with 
codes 81345, 81272, and 81314. 

You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a comprehensive cancer panel was provided. We looked at the file and Medicare rules. This 
panel testing was not billed with a single panel code as required. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the genetic testing provided on October 4, 2022, billed with codes 81345, 81272, and 81314.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gel pad footplates (K0108). 
 
You asked the Plan to pre-approve gel pad footplates. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request is more than the guidelines allow. You were approved for center mount 
power elevating leg rest/platform which includes all components of the leg rests including the footplates. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary.  

The file shows that you have been approved for center mount power elevating leg rest/platform (E1012). The 
center mount power elevating leg rest/platform serves the same purpose as gel pad footplates. Therefore, we 
decided that the Plan does not have to pre-approve gel pad footplates (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service October 28, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that the documentation shows medical necessity. 
The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 is a column II code to column I code 0089U. CPT code 81345 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
81345 billed for date of service October 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 1 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says 1 additional physical therapy 
visit is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you were functioning well at the 8th visits and can 
continue with a home exercise program. Although the plan approved 7 additional visits continued input from a 
skilled therapist is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on August 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received on August 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ultomiris (J1303). 
 
You asked the Plan to pre-approve Ultomiris. You say that Ultomiris is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says Ultomiris has been prescribed for an off-label, not medically 
accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Ultomiris. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Ultomiris is not FDA-approved for the enrollees diagnosis of seronegative Myasthenia 
Gravis. Furthermore, the use of Ultomiris for seronegative Myasthenia Gravis is not supported by one of the 
major drug compendia or by clinical research that appears in a Medicare-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ultomiris have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Ultomiris (J1303).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20103 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code 20103. You say that please review all of the attached 
documentation and reprocess accordingly. The Plan denied your request. The Plan says payment for code 
20103 is bundled into payment for code 25118. 
 
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 20103 
is a column II code to column I code 25118. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 20103 billed for date of service May 25, 2022.