Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the two endoscopic codes provided on 
February 2, 2023, billed with codes 43239 and 43255-59. 
 
You asked the Plan to make additional payment for the endoscopy services. You say that this was correctly 
billed with a modifier to allow payment for both codes.  The Plan denied your request. The Plan says the code 
was denied as it is bundled.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that both codes at issue have a Multiple Procedure Indicator of 3 on the Physician Fee Schedule. This 
means that special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy 
in the same family (i.e., another endoscopy that has the same base procedure).  
 In this case, both codes have an endoscopy base code of 43235. The base code payment rate for this state is 
$123.43. The code with the highest payment rate is 43255, which was paid in full. In addition, the difference 
between the rate for 43239 and 43235 was added to the payment of code 43255. This was correctly paid based 
on the endoscopy payment rules. Payment was not denied for 43239, but rather it was included in payment for 
43255. Based on this information, we decided that Medicare rules for coverage of the endoscopy services have 
not been met. Therefore, we decided that the Plan does not have to make additional payment for the two 
endoscopic codes provided on February 2, 2023, billed with codes 43239 and 43255-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on April 27, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered when the criteria in 
the rules section of this letter are met. 
 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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
definitive multi-drug testing was not medically necessary, and documentation does not support that criteria 
listed were met for coverage. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on April 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) (72158). 
 
You asked the Plan to pre-approve an MRI. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the records provided do not support the medical necessity for an MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the MRI was denied because there was no 
motor weakness, foot drop, cauda equina syndrome, fracture, or severe radicular pain. The medical records also 
show that the enrollee has had sciatic pain prior to her fall, and she has not had an acute worsening of 
symptoms or new neurological deficits. She also has not had a full six-week trial of conservative management, 
with pain medications such as Ibuprofen and no records of formal physical therapy. These are all valid points 
for denial, and there is no documentation to suggest she would need to undergo an MRI now. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) (72158).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing provided on May 19, 2023, billed with code 84156-59. 
 
You asked the Plan to pay for the lab testing as billed. You say that this claim should be paid.  The Plan denied 
your request. The Plan says that there is no reason given why the test needed to be performed twice on the 
same date.  
 
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. The Plan argues that this second unit of 84156 cannot be paid on the same date. 
However, the file does not include evidence that this test was billed and paid on the same date. Without a claim 
showing payment was made for 84156, we cannot confirm the Plan's denial rationale is appropriate.  Therefore, 
we decided that the Plan has to pay for the lab testing provided on May 19, 2023, billed with code 84156-59.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious agent detection testing provided on April 4, 2023. 
 
You asked the Plan to pay for 87635. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that the records do not include interpretation and report for the billed date of 
service. 
 
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 87635 is infectious agent detection by nucleic acid; severe acute respiratory syndrome coronavirus 2 
(COVID-19), 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 87635. Our reviewer says that this code meets criteria for 
payment. Our reviewer found the documentation submitted supports the use of this code as it has been billed on 
the claim. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87635 have been met. Therefore, we decided that the Plan has to pay for 
infectious agent detection testing provided on April 4, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivacaine used during a knee joint injection provided 
on May 15, 2023, billed with code J3490. 
 
You asked the Plan to pay for the bupivacaine. You say that this claim should be paid as billed.  The Plan 
denied your request. The Plan says J3490 is not separately payable from the code 20610. 
 
The Plan must follow Medicare rules. Medicare rules say that it is inappropriate to separately report services 
that are integral to the performance of another billed procedure. 
 
We looked at the file and Medicare rules. Payment for 20610, which is an injection into the joint space, would 
always include use of local anesthetic. As such, separately billing for the anesthetic would not be appropriate. Based on this information, we decided that Medicare rules for coverage of the bupivacaine have not been met. 
Therefore, we decided that the Plan does not have to pay for the bupivacaine used during a knee joint injection 
provided on May 15, 2023, billed with code J3490.
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 physical and occupational therapy 
to begin regaining their strength, balance and ability to complete activities of daily living. The Plan denied your 
request. The Plan says the enrollee's condition does not meet the Medicare guidelines for approval. 
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain his functional status.  The enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary. 
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab 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, at an intensive rehabilitation therapy program. There is not a reasonable expectation that 
this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the 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 that there is no documentation that you require skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. Records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care or respiratory care. 
Based on the medical records provided, there is no documentation that further daily skilled services are 
required. You appear to have plateaued with therapy. Further improvement in your functional status does not 
appear to be predictable in a reasonable time frame to necessitate further daily in-patient skilled therapy 
services; transition to part time therapy services now appears to be appropriate. There is no documentation that 
you require the services on an inpatient basis, only in a skilled nursing facility setting. Records support that 
services in the home with home health care or in a long-term care facility on a part time basis are appropriate 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.

You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF admission was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the records clearly show the enrollee's case was custodial in nature.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The medical records show the enrollee was 91 years old with kidney problems, diabetes, high blood pressure, heart failure, chronic obstructive pulmonary disease, and atrial fibrillation. The enrollee previously lived in a long-term care facility prior and then with family prior to the hospital stay. It was noted the enrollee was unable to care for herself at home and needed assistance to stand and walk. The enrollee had poor activity tolerance and her care needs were custodial in nature and not rehabilitative. Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve the requested services. You say that monitoring can reduce heart failure 
hospitalizations. The Plan denied your request. The Plan says the service is considered investigational.  
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). The system was requested to help 
improve fluid management and symptoms. Follow-up studies remain encouraging and suggest an improvement 
in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS.   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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466 x3 units). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee was hospitalized in September; 
there is no arterial blood gas done while stable to document chronic carbon dioxide (CO2) retention. If that is 
present, may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
supportautomated expiratory positive airway pressure (AVAPS-AE) during sleep. The records do not show 
this has been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466 x3 units).
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 LTACH services are medically 
necessary.  The Plan denied your request. The Plan says the LTACH services are not medically necessary, and 
the enrollee's needs can be safely managed in the current acute setting until medically stable for transfer to a 
lower level of care such as a skilled nursing facility.  
 
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 was admitted with acute on chronic hypoxic and hypercapnic respiratory 
failure secondary to pneumonia and chronic obstructive pulmonary disease exacerbation. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services, and these have not been denied.  
 
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.