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

 
We decided that the Plan does not have to pay for the urinary tract infection pathogen detection panel provided 
on September 2, 2022, billed with codes 87481, 87653, 87801, and 87798. 
 
You asked the Plan to pay for the pathogen detection panel as billed. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this panel was not billed correctly.  
 
The Plan must follow Medicare rules. Medicare rules say that a single laboratory procedure shall be reported as 
one unit of service whether it generates one or multiple results. When multiple procedures, multiple 
methodologies, or multiple kits are medically necessary and used, additional units may be covered.   
 We looked at the file and Medicare rules. The file shows that the pathogens were tested using the nucleic acid 
probe technique. There is no evidence that additional procedures, methodologies, or kits were used. Based on 
this information, we decided that Medicare rules for coverage of the wound infectious agent panel as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection 
pathogen detection panel provided on September 2, 2022, billed with codes 87481, 87653, 87801, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for astigmatism (PCIOL) correction provided on September. 20,
2022.

You asked the Plan to pay for this service. The Plan denied your request. The Plan says this treatment is an
upgrade to the traditional surgery and is not covered by the Plan or by Medicare. Maximus overturned the Plans
denial. The Plan requested a reopen and noted that the provider confirmed you were educated that this was an
elective procedure to correct your astigmatism, that it was not covered and would be your financial liability.

The Plan is correct in this case. The Plan covers all items that Medicare covers. Medicare rules say that if an
enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost
between the P-C IOL and a conventional IOL. While a P-C IOL may have been appropriate for you, neither the
Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan
does not have to pay for astigmatism (PCIOL) correction provided on September. 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that to pre-approve Our physician reviewer found clinical documentation does not specify any plan of care 
or medication changes. Clinical documentation does not show any acute clinical status changes thus the records 
do show that 9 additional home health skilled nursing visits are required to effectively provide treatment, care, 
and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 home health skilled nursing visits.
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 LTACH services. You say that the enrollee has a medical necessity for a 
LTACH admission. The Plan denied your request. The Plan says the enrollee still has acute care needs and 
does not appear to be stable for transfer to a 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 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 appears to require additional acute care services that can safely be 
provided at the current facility until more stable and appropriate for transfer. The enrollee does not require 
services at the LTACH level that are not already available at the current facility. Transfer to an LTACH is not medically necessary and would not be clinically advantageous. Completion of treatment at the current facility 
is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH 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 services are medically necessary. The Plan 
denied your request. The Plan says based on the available information, admission to an IRF is not reasonable 
and 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 that in this case, the complexity of the members 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 the enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry (83789-59) provided June 20, 2023. 
 
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 the service is not covered as billed. 
 
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 83789 is a column II code to column I code G0480; however, 83789 
was 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 the service. Our reviewer found the documentation describes 
urine drug testing with specimen validity testing. The providers performing validity testing on urine specimens 
utilized for drug testing shall not separately bill the validity testing. For example, if a laboratory performs a 
urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not 
adulterated, this testing is not separately billed. 
 
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 the mass spectrometry (83789-59) provided June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a ventilator. 
 
You asked the Plan to pre-approve continued use of 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 continued use of a ventilator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
require home ventilator and does not meet criteria provided. Documentation shows that the enrollee is only 
10% compliant with intelligent volume assured pressure support (IVAPS) therapy. No indication to continue 
per documentation with lack of support for compliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued use of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce any of the cost share charged for services rendered
on June 13, 2022, and October 10, 2022.

You asked the Plan to waive this cost share. The Plan denied your request. The Plan says this cost sharing was
charged correctly. Maximus overturned the Plans denial.

Maximus partially overturned the Plans denial and stated that Maximus did not apply the correct contract
coverage. The Plan noted that treatment was sought from an Ophthalmologist is a medical doctor. The
service in question, whose description is "Ophthalmological medical examination and
evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established
patient". This service was a medical examination. The claims were billed diagnosis H35.3212 for exudative
age-related macular degeneration, right eye, with inactive choroidal neovascularization. As this was a
medical doctor who specializes in eye and vision care, and was treating a disease, the cost share charged was
done so correct.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan
clearly states there is a cost share for diagnostic vision services and Medicare Part B injections. You have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive any of the cost share charged for services provided on June 13, 2022, and October 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the continuation of SNF care is not medically necessary. 
 
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 you do not require daily skilled nursing or therapy services. You do not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. You asked the Plan to pre-
approve home health services. You say that you would like reconsideration based on the records submitted.  
The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
Records document the enrollee has been educated on her disease process, proper diet, glucose monitoring, 
emergent care, safety measures and medications. No medical notes from the enrollee's treating physician are 
provided documenting an order or need for additional skilled nursing services. Records do not document the 
need for intravenous medications, new tube feeding or ostomy care or complex wound 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided to the enrollee
from November 3, 2022, to November 17, 2022.

You asked the Plan to pay for the electrical stimulation. You say that these services were medically necessary.
The Plan denied your request. The Plan says that the use of electrostimulation alone for neuropathies or
peripheral neuropathies caused by underlying systemic diseases, is insufficient to warrant coverage. Maximus
overturned the Plan's denial. The Plan requested a reopening and stated that these services were not covered by
Medicare. The Plan is correct in this case. Medicare rules say that the use of nerve blocks with or without the
use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or
peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and
necessary. Therefore, we decided that the Plan does not have to pay for the electrical stimulation (G0283)
provided to the enrollee from November 3, 2022, to November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or stenosis. The cause of the pain is not clear.  
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee can receive the care they need 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required can be provided 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says admission to an LTACH is not medically necessary.  
 
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 appears to have been improving but is still somewhat unstable and 
requires additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous.  
 
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 the lab services (83520 - 5 units) and (87798-XU - 1 unit) 
provided January 27, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism.  
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 laboratory services. Our reviewer found the records 
document the enrollee in this case had a diagnosis of diarrhea, unspecified. A Comprehensive Diarrhea Panel, 
Fecal Immunoassays and Additional Stool Diagnostic Tests were ordered. The remaining supplied records 
document the test results. Provided medical and laboratory records in this case are inadequate to clarify which 
of the test results are represented by the five units of 83520 that were billed. Similarly, provided medical and 
laboratory records in this case are inadequate to clarify which test result is represented by the one unit of 87798 
that was billed.   
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services (83520 - 5 units) and (87798-XU - 1 unit) provided January 27, 2023.