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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you currently struggle with neuropathy from your 
hips to your feet and have very little strength in your upper body and require physical and occupational therapy 
services. The Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does not meet the criteria for 
an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria 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 the enrollee is receiving appropriate care in the current acute care setting as 
provided by Health Plan. The documentation does not support that LTACH services are medically appropriate 
at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87641 and 87798 billed for date of 
service September 23, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87641 and 87798. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says payment for codes 87150, 87641 and 
87798 is bundled into payment for codes 87801 and 87500. 
 
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 87150 is a column II code to column I code 87500 and that codes 
87641 and 87798 are column II codes to column I code 87801; however, codes 87150, 87641 and 87798 were 
billed with a modifier.  
 
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 procedure codes 87150, 87641 and 87798. Our reviewer says 
that procedure codes 87150, 87641 and 87798 do not meet criteria for payment. Our reviewer found that the 
procedures at issue were reported with modifier XU (Unusual non-overlapping service) to bypass the edit; 
however, the laboratory report does not include documentation to support unusual non-overlapping services. 
Therefore, the procedures at issue 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 procedure codes 87150, 87641 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150, 87641 and 87798 billed for date of 
service September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for services billed to the enrollee under code(s) 87798-59 x13, 87481-59 x 5, and 87801x3 for October 19, 2022.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and noted that a test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components although the test reports multiple individual pathogens and/or targets. The Plan approved code 87801 for one unit as is allowed by Medicare. All other codes were upheld due to unbundling of services rules.
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 Medicare rules for unbundling codes for a lab panel. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for services billed to the enrollee under code(s) 87798-59 x13, 87481-59 x 5, and 87801x3 for October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at home visit provided on March 07, 2023. 
 
You asked the Plan to pay for an at home visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an at home visit 
provided on March 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sinus augmentation (D7952) provided on July 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that the cost should be paid by the Plan. The Plan 
denied your request. The Plan says your annual dental maximum benefit for the year 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 Plan's 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 Plan paid $639 for dental services on April 11, 2022. On July 28, 2022, the Plan paid $1,522.35 for 
dental services. On December 1, 2022, which was processed prior to the claim for July 28, 2022, the Plan paid 
$838.65. For the year of 2022 the Plan paid $3,000 ($639 paid + $1,522.35 paid + $838.65 paid) for dental 
services; therefore, your annual dental maximum benefit for the year of 2022 was exhausted on the date of 
service of December 1, 2022. Therefore, we decided that the Plan does not have to pay for the sinus 
augmentation (D7952) provided on July 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 (2 units) billed for date of service 
December 21, 2022.  
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this code is not supported in the medical record.  
 
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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique.  

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 service. Our reviewer found given that code 87801 
(infectious agent detection by nucleic acid, multiple organisms, amplified probe technique) was billed and paid, 
records do not clarify that billing for 87481 also is appropriate in this case. In addition, provided medical 
records only include a signed practitioner order for a "U/A with micro." No signed practitioner order for 
infectious agent detection by nucleic acid is provided.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87481 (2 units) billed for date of service December 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve subcutaneous cardiac rhythm monitor (implantable loop 
recorder [ILR]). 
 
You asked the Plan to pre-approve the ILR device. You say that this can be covered for cryptogenic stroke and 
management of atrial fibrillation. The Plan denied your request. The Plan says the enrollee has not had syncope 
and therefore this cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that a n ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate the enrollee would benefit from renewing the ILR device. The documentation does not 
support any significant symptoms or recurrent syncope. The reviewer also found that the enrollee is already on 
a well-tolerated full anticoagulation. Therefore, the reviewer found that the requested ILR device is not 
medically reasonable or 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 ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve subcutaneous cardiac rhythm monitor (implantable loop recorder [ILR]).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sleep study (95800) provided on March 8, 2023, by an 
out-of-network (OON) provider.  
 
  You asked the Plan to pay for the sleep study. You say that the Plan's website does not state that a pre-
certification is required for a home sleep test. You also say that you would like this claim to be reprocessed and 
paid at 100% of the allowable stated under your contract since it does not specify that a pre-certification is 
required for the home sleep test. The Plan denied your request. The Plan says this service was rendered by a 
non-network provider who does not work with the enrollee's plan, and the enrollee was referred by another 
non-network provider. The Plan also says that no medical necessity for an OON provider, such as an urgent or 
emergency situation, has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the sleep study (95800) provided on March 8, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on February 10, 2023, billed with 19 
units of code 87798. 
 
You asked the Plan to pay for the lab testing as billed. You say that this testing was clinically valuable and 
should be paid.  The Plan denied your request. The Plan says a report of the results of the lab testing were not 
submitted despite requests for this information.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab testing as billed have been met. 
The provider in this case has not submitted a lab report showing the results of testing in order to verify that the 
codes submitted are appropriate. Therefore, we decided that the Plan does not have to pay for the lab testing 
provided on February 10, 2023, billed with 19 units of code 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical navigation 
(0055T). 
 
You asked the Plan to pre-approve computer-assisted musculoskeletal surgical navigation. You say that this is 
medically necessary. The Plan denied your request. The Plan says this 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 computer-assisted musculoskeletal 
surgical navigation. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there are no large volume, long-term/high-
quality clinical studies that confirm the clinical benefits (ultimate outcomes of functional improvement and 
pain reduction) of computer-assisted surgery over standard surgical approaches in total shoulder arthroplasty. 
No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of 
this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted musculoskeletal surgical navigation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical 
navigation (0055T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on January 
24, 2023. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that you disagree with the 
deductible. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
You have been asked to pay $91.66 towards your deductible for the specialist office visit. The item or service 
you asked the Plan to waive the deductible for falls within the physician/practitioner services, including 
doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $300 deductible which applies to physician/practitioner services, including doctors 
office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist office 
visit was received on January 24, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for a specialist office visit provided on January 24, 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 you need to be readmitted due to medical needs. The 
Plan denied your request. The Plan says the services you need can be provided safely in other settings. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and 
continues to require extensive rehabilitative therapies to regain strength and functional quality of life. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and related supplies 
provided on December 23, 2022. 
 
You asked the Plan to pay for the CGM and related supplies. You say that the enrollee is eligible for the 
product under Medicare guidelines. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
The Plan follows 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 pay for the CGM and related supplies. Our reviewer 
says that the coverage criteria for the CGM and related supplies was not met. Our physician reviewer found 
that the review has determined that the enrollee has diabetes mellitus. The enrollees treating practitioner has 
not concluded that the enrollee or their caregiver has sufficient training using the CGM prescribed, as 
evidenced by providing a prescription. The requested CGM is not prescribed in accordance with its food and 
drug administration indications for use as the enrollee is not insulin treated. The enrollee does not have a 
history of problematic hypoglycemia. The documentation provided does not support that within 6 months prior 
to ordering the CGM, the treating physician had an in-person or Medicare-approved telehealth visit with the 
enrollee to evaluate their diabetes control and determine whether criteria for coverage are 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 the CGM and related supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for a continuous glucose monitor (CGM) and related supplies provided on 
December 23, 2022.