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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The
Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) services you are
requesting do not meet the requirements for approval.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that the complexity of the patient's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient's medical conditions appear improved on stable outpatient medications with no issues that appear
to require a physician's evaluation three or more times per week in a hospital setting. The patient does require
physical therapy and occupational therapy services, but the medical records provided do not clarify why the
patient requires an intensive inpatient rehabilitation therapy program. Provided medical records do not support
that the intensive inpatient rehabilitation therapy program is necessary and that therapy at a lower level of care
such as in a skilled nursing facility is not appropriate for the patient. The patient would be expected to
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility, however the medical records do not support a complexity of needs to require an acute
inpatient rehabilitation facility over a skilled nursing facility. Our Medical Director found that the enrollee's
condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
pneumatic appliances (E0667, E0673) provided December 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that you are appealing 
the claim denial for being not covered. The Plan denied your request. The Plan says pneumatic compression 
device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and segmental pneumatic appliances (E0667, E0673) 
provided December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the specific testing provided in this case. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on May 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the harvesting of organs (01990) and arterial catheterization 
or cannulation for sampling, monitoring or transfusion (36620) provided on October 17, 2022. 
 
You asked the Plan to pay for the transplant services. You say that this claim should be reprocessed and paid. 
The Plan denied your request. The Plan says the services in this case are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procuring an organ is not a covered service when 
performed independent of a Medicare covered transplant. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transplant services have not been met. Specifically, the provider has failed to provide evidence 
showing that the organ was procured in relation to a Medicare-covered transplant. Therefore, we decided that 
the Plan does not have to pay for the harvesting of organs (01990) and arterial catheterization or cannulation 
for sampling, monitoring or transfusion (36620) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says that based on the information submitted, there is no documentation that you meet the criteria for coverage. Maximus overturned the Plan's denial because they did not include the relevant EOC. The Plan has requested a reopening and now provided the 2023 Evidence of Coverage for review.
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a documented chronic condition that is life threatening or significantly limits the health or function of the enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive care management. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 25, 2023, to 
February 23, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 25, 2023, to 
February 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 25, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0728, 
A0425). 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee does not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport. Transportation can be provided by other means without endangering the 
enrollees 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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0728, A0425).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 85025. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 85060.  
 
You asked the Plan to pay for practitioner services provided on May 11, 2023, billed with procedure codes 
85025 and 85060. You say that the claim is billed correctly and should be paid. The Plan says that 85060 was 
billed with an inappropriate place of service for physician interpretation. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 85025.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 85025.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
85060. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
We looked at the file, and Medicare rules. This claim was billed with place of service 11, which is 
inappropriate for code 85060. Based on this information, we decided that Medicare rules for coverage of the 
services described by procedure code(s) 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code(s) 85060. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the nerve conduction study provided on August 26, 2022, and the betamethasone acetate injections provided on June 7, 2022, and September 10, 2022.
You asked the Plan to waive the cost-sharing for the nerve conduction study and injections. You say that these copayment amounts have changed and are too high. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated that we did not apply the correct criteria.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment for other diagnostic procedures and tests, including a nerve study and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $95 copayment for the nerve conduction study and a 20% coinsurance for the injections. This the nerve conduction study falls within the other diagnostic procedures and tests, including a nerve study and the injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for the nerve conduction study provided on August 26, 2022, and the betamethasone acetate injections provided on June 7, 2022, and September 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have submitted medical records to support the 
request for reconsideration of the authorization denial of continued admission in a skilled nursing facility. You 
are very weak, and you have had multiple falls from the bed. The Plan denied your request. The Plan says the 
skilled nursing facility (SNF) services requested do not meet the requirements for approval. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you disagree with the Plan's 
decision. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 13, 2023, to 
June 17, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct bill type. 
 
The Plan follows Medicare rules. The rules say that home health services must be billed with the correct type 
of bill. 
 
We reviewed the file and the Medicare rules. We find that the type of bill on the claim was submitted as 0323. 
This is an incorrect type of bill for the services rendered. Based on this information, we find that the Medicare 
rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from June 13, 2023, to June 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on May 11, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on May 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92960 and 99152 for date of service April 8, 
2023. 
 
You asked the Plan to pay for procedure codes 92960 and 99152. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 92960 is cardioversion, elective, electrical conversion of 
arrhythmia; external. 
 
 The CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician 
or other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or 
older. 
 
We find that CPT codes 92960 and 99152 are not supported in the medical record. Specifically, the submitted 
medical records include a progress note that indicates the billed services were performed by a health care 
provider other than the billing health care provider. This means code 92960 cannot be verified. The submitted 
medical records do not support at least 10 minutes of sedation which is the minimum requirement needed in 
order to bill this code. Therefore, code 99152 is not supported. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 92960 and 99152 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 92960 and 99152 for date of service April 8, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with ravulizumab (J1303). 
 You asked the Plan to pre-approve ravulizumab. You say that ravulizumab is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of ravulizumab have not 
been met. 
 
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 ravulizumab. Our reviewer says that 
treatment with ravulizumab is not medically reasonable and necessary in this case. Our physician reviewer 
found that the Plan requires a 12-month trial of immunosuppressive therapy before they will approve the 
requested drug. The enrollee has myasthenia gravis. The requested drug is a new start. The provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step-one alternatives. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred 
step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ravulizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with ravulizumab (J1303).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 10, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88361 billed for date of service May 18, 
2023.  
 
You asked the Plan to pay for procedure code 88361. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88361 is 6. The MAI value for this code is 2. You billed 8 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88361 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88361 billed for date of service May 18, 2023.