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

 
We decided that the Plan does not have to pay for procedure code 87631 for date of service March 6, 2023. 
 
You asked the Plan to pay for procedure code 87631. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87631 for date 
of service March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve implantable loop recorder (ILR). You say that this will benefit the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules state that an implantable loop recorder may be covered when 
syncope is thought to be cardiac-related but is too infrequent to be detected by either a Holter monitor or 
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 implantable loop recorder (ILR). Our 
reviewer says that the enrollee does not meet criteria for an ILR. Our physician reviewer found there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent 
indication for an ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable loop recorder (ILR) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99441 for date of service November 16, 
2022. 
 
You asked the Plan to pay for procedure code 99441. 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 99441 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion. 
 We find that CPT code 99441 is not supported in the medical record. Specifically, the documentation did not 
include medical records for this date of service. This means this service is not supported by the documentation. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99441 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99441 for date of service 
November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. 
The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a 
Skilled Nursing Facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service August 26, 
2022, to September 24, 2022. You asked the Plan to pay for the billed services. You say that you were informed the NOA was received. The 
Plan denied your request. The Plan says the NOA was not received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 26, 2022. A valid NOA was not received by the Plan until 
December 15, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health care billed for dates of service August 26, 2022, to September 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the brain, an MRA of the head, an MRI of 
the spine, and an MRA of the neck to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an MRI of the brain, an MRA of the head, an MRI of the spine, and an 
MRA of the neck. You say that you are appealing this denial. The Plan denied your request. The Plan says the 
enrollee must receive care from a network provider  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an MRI of the brain, an MRA of the head, an MRI of the spine, and an MRA of the neck to be provided by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 very heavy-duty power wheelchair with a 
patient weight capacity 451 to 600 pounds (K0826). 
 
You asked the Plan to pre-approve a Group 2 very heavy-duty power wheelchair. The Plan denied your request. 
The Plan says this request cannot be approved per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 power wheelchair (PWC) (such as 
K0826) is covered if all of the basic coverage criteria for a PWC are met and the wheelchair is appropriate for the beneficiarys weight. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the enrollee's weight is 380 
pounds, which is less than the required weight for the requested wheelchair. Based on this information, we 
decided that Medicare rules for coverage of a Group 2 very heavy-duty power wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 very heavy-duty power wheelchair 
with a patient weight capacity 451 to 600 pounds (K0826).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator.  
 
You asked the Plan to pre-approve an auricular stimulator. You say that this is not a spinal cord stimulator, 
PSTIM, nor is it considered acupuncture. You say that your goal is to help alleviate the enrollee's current pain 
and increase the enrollee's ability to participate in day-today activities with reducing or alleviating the need or 
use of opioid medications.  The Plan denied your request. The Plan says neither Medicare nor their contract 
covers the requested device. The Plan says that medical studies haven't proven this item is helpful for the 
treatment of the enrollee's health problem.  
 The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation will be 
denied as non-covered.  Therefore, we decided that the Plan does not have to pre-approve an auricular 
stimulator.
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 the services are medically necessary for the enrollee 
to optimize independence with functional mobility. The Plan denied your request. The Plan says the records do 
not show that the enrollee requires daily skilled services that can be provided only on an inpatient basis in a 
SNF.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the infliximab injection provided on February 10, 2022.
You asked the Plan to reduce the coinsurance for the infliximab injection. You say that the intravenous portion of your bill is charged wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus miscalculated. The Plan is correct in this case. You have been asked to pay a 20% coinsurance for the infliximab injection. The total cost of the drug was $1,507.28. 20% of $1,507.28 is equal to $301.46. This is the amount you have been charged. This item/service falls within the Medicare-covered Part B drug 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 reduce the coinsurance for the infliximab injection provided on February 10, 2022.
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 the enrollee does not meet all the requirements 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 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 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87506 and 87324 provided on January 15, 
2023. 
 
You asked the Plan to pay for procedure codes 87506 and 87324. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing (87506) did not include the required unique identifier. Additionally, we find that payment for 
code 87324 is bundled into payment for code 87506. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. 
Review of the claim does not show that the required unique identifier was reported for procedure code 87506.  
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 87324 is a column II code to column I code 
87506. This claim has not been billed with an appropriate modifier to bypass the edit. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87506 and 87324 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87506 and 
87324 provided on January 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT), heart, without contrast
material, with quantitative evaluation of coronary calcium (75571) for the enrollee.
You asked the Plan to pre-approve the CT. You say that this service is medically necessary. The Plan denied
your request. The Plan says that this is not a covered test. Maximus overturned the Plan's denial. The Plan
requested a reopening and stated this service was not denied based on medical necessity but Medicare coverage
rules. The Plan is correct in this case. We looked at the file and Medicare rules. Medicare rules confirm this
service is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of
the CT have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed
tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium (75571)
for the enrollee.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show that the enrollee can tolerate 3 hours of 
therapies per day. Services can be reasonably expected to improve at a lower level of care with good success. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 can tolerate 3 hours of therapy 5-6 days 
week in IRF setting and is motivated and would like to return home to an independent lifestyle. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 pay for subsequent nursing facility care services provided on 
December 30, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the provider is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that since this provider is not certified for Medicare 
participation, they are not eligible for payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the subsequent nursing facility care services have not been met. Therefore, we decided that the 
Plan does not have to pay for subsequent nursing facility care services provided on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services billed to the enrollee for May 12, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says there is a discrepancy between the medical records and the billing provider.
Maximus overturned the Plan's decision stating the records support the services billed. The Plan requested a reopen and stated that the issue was not medical necessity but that the records provided document the services were performed by a provider other than the billing provider. The Plan is unable to find any relationship between both providers. The physician listed in the medical records practices under Emergency Medicine. The services were performed and the billing provider is listed in the NPI registry under Physical Medicine and Rehabilitation facility. Based on the Medicare billing guidelines, this claim should not be paid.
The Plan is correct in this case. 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. The servicing provider in the medical records does not match the billing provider on the claim. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee for May 12, 2022.