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

 
We decided that the Plan does not have to pay for the therapy services provided on January 6, 2023. 
 
You asked the Plan to pay for the services. 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes R26.9 and 
R27.0. Diagnosis code R26.9 has an Excludes1 note and cannot be billed with diagnosis code R27.0. 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 therapy services provided on January 6, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the request 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollees has complex nursing and rehabilitation needs. The medical record supports a need for 
physical and occupational therapy. Additionally, there a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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: 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 you are requesting reconsideration for 
the denial of LTACH services since the enrollee will benefit from rehabilitation at the LTACH level of care.  
The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service November 30, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the tests were medically necessary. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
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 the wound care panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing billed for date of service November 30, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee currently has five fractures in the spine. 
You say that the enrollee will not have a fast enough response from either oral or intravenous (IV) 
bisphosphonate therapy. You also say that the enrollee is at very high risk for additional fractures. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, an oral 
bisphosphonate and an intravenous (IV) bisphosphonate. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed an oral bisphosphonate and an intravenous (IV) bisphosphonate. The reviewer 
also found that there is no documentation provided indicating that the Plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step 
therapy criteria have not been 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Step-Therapy
Decision: Unfavorable

  
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 You asked the Plan to pre-approve Aranesp. You say that this medication is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Retacrit or Procrit. 
 
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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed the preferred drugs, Retacrit or Procrit. The reviewer also found that 
there is no documentation provided indicating that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria 
have not been 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) treatment 
(90867). 
 
You asked the Plan to pre-approve TMS treatment. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the medical necessity criteria 
for TMS are not met. 
 
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 TMS treatment. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the information provided in utilizing LCD L33398, this enrollee does not meet the 
clinical criteria for the use of Transcranial Magnetic Stimulation (TMS) therapy as the enrollee has not taken 
alternative medications required by the criteria in the current depressive episode. The enrollee has not 
undergone psychotherapy and has not undergone electroconvulsive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation (TMS) treatment (90867).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 9, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment cannot be 
made in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The rules also say that model payments for Transport to an Alternative Destination and 
Treatment in Place interventions will be made available for Medicare Fee-for-Service beneficiaries only. 
 The ambulance services in this case were billed with modifier RW, which indicates the services were provided 
as Treatment in Place or via Telehealth Service. These services were billed under ET3, which is only payable 
for Original Medicare beneficiaries, and not for Medicare Advantage Plans. Therefore, we decided that the 
Plan does not have to pay for the ambulance services provided on January 9, 2023.
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 you are requesting an expedited appeal 
as the enrollee clearly exceeds the criteria for an appropriate LTACH admission. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for admission to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone pellets. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have 
complications after a hysterectomy. The Food and Drug Administration (FDA) has not stated that the requested 
drug is indicated for your condition. The Medicare approved drug compendia do not support the use for your 
condition. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve testosterone pellets.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the inpatient hospital admission on May 29, 2023.  
 
You asked the Plan to pre-approve the inpatient admission. You say that the enrollee was not unconscious and 
unable to give identification information upon arrival.  The Plan denied your request. The Plan says that the 
Plan was not notified of the admission in time. As such, the care provided cannot be approved.  
 
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 has not provided a valid argument regarding the denial of the inpatient 
admission. While there may be an agreement regarding timely notification of admission between the Plan and 
the network provider, Maximus can only review whether the admission is/was medically necessary. Given that 
the enrollee was admitted with a gunshot wound and has been in the facility for at least two months, we find 
that the criteria regarding inpatient admission are clearly met. Any issue of the date/time of the notification is a 
matter of contract between the Plan and the facility.  Therefore, we decided that the Plan has to pre-approve the 
inpatient hospital admission on May 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
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 pre-approve a CGM. Our reviewer says that the item 
is not medically necessary. Our physician reviewer found you do not meet the coverage criteria for this item. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81521) provided on January 31, 
2020. 
 
You asked the Plan to pay for the laboratory services. You say that this testing is covered by Medicare. The 
Plan denied your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 
81521 are not covered. 
 
We looked at the file and Medicare rules. The code at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (81521) provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the allergen immunotherapy (95117) provided on November 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed place of 
service is inappropriate for this procedure. 
 
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 the billed place of service is inappropriate for this 
procedure. However, the Plan has only cited Medicare rules showing that modifier 25 must be used for 
payment for visit services provided on the same day as allergen immunotherapy services. First, the services at 
issue in this case are not visit services. Secondly, the Plan has not provided any documentation supporting that 
the billed place of service is not appropriate for the services provided. Without supporting documentation, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the allergen 
immunotherapy (95117) provided on November 2, 2022.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87841 and 87798 for date of service 
November 9, 2022. 
 
You asked the Plan to pay for procedure codes 87841 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service. A panel cannot be unbundled.  
 
 
 We looked at the file and Medicare rules. A panel cannot be unbundled. Review of the file shows that the panel 
provided was not billed with a single service. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 87841 and 87798 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87841 and 87798 for date of service November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99205, 83014) provided on February 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
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 services. Our reviewer says that the use of codes 99205 
and 83014 is not supported by the records provided. Our reviewer found that the key elements of code 99205 
representing medical decision making are not present. The complexity is moderate, not high. The data 
complexity was low, and the risk was moderate. This meets criteria to report 99204, not 99205. For CPT code 
83014, there is nothing in the record that mentions drug administration for H pylori. The focus of this visit was sinusitis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99205, 83014) provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81401, 81403, 81405 and 81406 billed for 
date of service June 11, 2021. 
 You asked the Plan to pay for procedure codes 81401, 81403, 81405 and 81406. You say that these services 
were reported appropriately and are supported in the medical record. The Plan denied your request. The Plan 
says these services are not supported for separate payment. 
 
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 codes 81401, 81403, 81405 and 81406 are column II codes to column I 
code 81442; however, 81401, 81403, 81405 and 81406 were each 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 81401, 81403, 81405 and 81406. Our 
reviewer says that the XS modifier is not supported with these codes. Our reviewer found the laboratory report 
does not include documentation to support that these services were provided for a separate structure; therefore, 
these codes would be included in the reported panel. 
 
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 81401, 81403, 81405 and 81406 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 81401, 81403, 81405 and 81406 billed for 
date of service June 11, 2021.