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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee.  
The Plan denied your request. The Plan says the services the enrollee requires can be received in another 
setting such as 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, and 
harness. 
 
You asked the Plan to pre-approve upgraded electronics. You say that the enrollee needs these features. 
 The Plan denied your request. The Plan says the requested upgraded electronics are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve upgraded electronics. Our reviewer says 
that the requested upgraded electronics are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the provided documentation indicates the enrollee has adequate strength to manage 
standard power drives. Therefore, the reviewer found that the request for upgraded electronics is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection, expandable controller, and harness.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the KnowError DNA Specimen Provenance Assay and DNA 
Specimen Provenance Assignment genetic testing provided on June 15, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says DNA Specimen Provenance Assignment and KnowError DNA 
Specimen Provenance Assay genetic testing are not a covered benefit. 
 
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. The rules also say that tests performed to measure the quality of a process do 
not provide information to diagnose or treat a patient illness or injury as defined in the Medicare benefit 
category. 
 
We looked at the file and Medicare rules. Medicare records do not show that DNA Specimen Provenance 
Assignment genetic testing is approved through the MolDX contractor. The KnowError DNA Specimen 
Provenance Assay is a statutorily excluded test. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
KnowError DNA Specimen Provenance Assay and DNA Specimen Provenance Assignment genetic testing 
provided on June 15, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for short-latency somatosensory evoked potential (SSEP) study, provided to the enrollee on August 23, 2022, and billed under code 95938.
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 the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that it is agreed that the SSEP testing was performed during the surgical procedure, however, the medical records received document that SSEP was performed only on the upper extremities. There is a more appropriate code (95925- Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs) that should be billed for the services performed. Code 95938 should only be billed when both upper and lower extremities are examined.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the records show only the upper extremities were tested. Therefore, code 95938 would not apply in this case. Medicare rules for coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pay for short-latency somatosensory evoked potential (SSEP) study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system provided to the enrollee on August 23, 2022 under code 95938.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the copayment paid for a computed tomography (CT) scan provided on September 7, 2022.
You asked the Plan to reimburse you this cost share. You say that you believed these services were authorized. The Plan denied your request. The Plan says while these services were not authorized. However this was a contract provider and the Medicare allowed amount of this service is less than or the same as your normal contractual co-payment. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus basically agreed with the Plan that you owed the cost share, and this should not have been a partial overturn.
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. Your contract with the Plan clearly says that you must pay a $350 copayment for CT scans. 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 reimburse you the copayment paid for a computed tomography (CT) scan provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 2, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 2, 2022.
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 the services the enrollee needs can be provided safely in another setting 
such as 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on December 7, 2021. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the Plan follows Medicare timely filing guidelines for billing of claims which states 
claims must be filed no later than 12 months after the date when the services were provided. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for an office visit was not filed until December 30, 2022. In order to 
receive payment, the corrected claim should have been filed no later 12 months after the date of service. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on December 7, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myelography via lumbar injection (62302), and 
computed tomography (CT) scan of cervical spine with contrast (72126). 
 
You asked the Plan to pre-approve imaging services. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says the requested imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve imaging services. Our reviewer says 
that the requested myelography and CT scan are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the provided documentation does not support that you have completed any 
physical therapy (PT). The reviewer found that the provided imaging did not allow adequate evaluation of the 
intervertebral foramen due to metallic artifact. The reviewer found that you are not a candidate for surgery. 
There is no red flag in this case and there is no contraindication to the already ordered course of PT prior to 
approving CT myelogram cervical spine. Therefore, the reviewer found that the requested imaging servies are 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of imaging services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a myelography via lumbar injection (62302), and computed tomography (CT) scan of 
cervical spine with contrast (72126).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 provided on August 2, 2022. 
 
You asked the Plan to pay for procedure code 99308. You say that the medical records support the billing of 
code 99308. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99308. 
 
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 99308 is Subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 15 minutes are spent at the bedside and on the patient's facility floor or unit.  
 
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 code 99308. Our reviewer says that the medical 
records do not support the billing of code 99308. Our reviewer found for the date of service August 2, 2022, the 
medical records did not support an expanded problem focused interval history, an expanded problem focused 
examination, or medical decision making of low complexity. 
 
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 code 99308 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99308 provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve out of network services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this service can be provided in network.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve out of network physician services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit (99285) provided February 23, 
2022. 
 
You asked the Plan to pay for the emergency visit. You say that the claim was paid at a lower level. You 
disagree with the review and have prepared a detailed letter of your review in order to appeal the ruling. The 
Plan denied your request. The Plan says the records do not support that the criteria has been met for 99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 emergency visit Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer 
found the medical records do not support level 5 emergency department evaluation and management. Level 4 is 
supported with the medical decision making for the visit. 
 
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 emergency visit have not been met. Therefore, we decided that the Plan 
does not have to pay for emergency department visit (99285) provided February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for care management services provided on January 05, 2023. 
 
You asked the Plan to pay for care management services. You say that it was not possible to obtain 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for care management 
services provided on January 05, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99232 billed for date of service March 22, 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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim documentation in the file. The Plan requested a reopen and provided the required documentation. The Plan noted that a claim was dates of service March 19, 2022, to March 22, 2022, and held pending medical record submission. Code 99232 was billed on the claim for date of service March 22, 2022. The other dates of service on this claim were processed and paid. An additional claim for March 22, 2022, was submitted on March 26, 2022. The Plan processed and paid the provider on April 12, 2022, for code 99233. The charge for date of service March 22, 2022, was already paid to the provider for code 99233 therefore code 99232 was upheld by the plan. Per Medicare claims processing Manual Chapter 12 Section 30.6.9 B. B. Two Hospital Visits Same Day A/B MACs (B) pay a physician for only one hospital visit per day for the same enrollee, whether the problems seen during the encounters are related or not. The inpatient hospital visits descriptors contain the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.
The Plan is correct in this case. 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 code 99232 is always bundled into payment for other services (99233) billed the same day by the same provider under the physician fee schedule. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 99232 billed for date of service March 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 7, 2022, to 
May 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 7, 2022, to May 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine exam  
 provided on July 7, 2022. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine exam. The Plan denied your 
request. The Plan says per the members benefit plan; non-Medicare covered routine physical exams are 
covered once every calendar year. The member had a preventative visit on June 3, 2022. 
 
The Plan contract says that the Plan covers an annual routine preventive physical exam. Non-Medicare covered 
routine physical exams are covered once every calendar year.  
 
We looked at the file and the Plans rules. The file shows that had a routine preventive physical exam on 
June 3, 2022. Therefore, we decided that the Plan does not have to pay for a periodic comprehensive preventive 
medicine exam provided on July 7, 2022.