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

 
We decided that the Plan does not have to pre-approve Odansetron. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Odansetron.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for code 47490 billed for January 16, 2022, under Claim A.
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 information in the case file. The Plan requested a reopen and provided the required claim information. The Plan demonstrated that this service is included in the global surgery package billed on a previous claim. This service is included in the global follow-up period. The denial for procedure 47490 was due to the relation to surgery procedure 47531, which is a minor procedure that has a global surgery period of 10 days. Payment for code 47490 is included within the global surgery package of procedure 47531.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to its inclusion in the global surgery package for code 47531 billed on a separate claim. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 47490 billed for date of service January 16, 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 enrollee requires a translator and will have access 
to one at the IRF. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level 
of care. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 pay for procedure code K1018 billed for date of service December 
15, 2022.  
 
You asked the Plan to pay for procedure code K1018. You say that the enrollee is benefitting from the therapy. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code K1018 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code K1018 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code K1018 billed for date of service December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 23, 2022, billed with 
codes 81230, 81231, 81232, 81291, 81306, 81355, 0031U, 0032U, 0033U, and 81238 . 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 23, 2022, billed with codes 81230, 81231, 81232, 81291, 81306, 81355, 0031U, 0032U, 0033U, and 
81238 .
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 billed for date of service January 10, 
2023.  
 
You asked the Plan to pay for procedure code 11042. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11042 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 11042 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11042 billed for date of service January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry care for debridement of toenails.  
 
You asked the Plan to pre-approve podiatry care for debridement of toenails. You say that your big toenail on 
your left foot is split, and you have occasional pain, and you can feel pressure on your toe and on the side of 
your foot when wearing shoes so you have had to wear sandals. You say that you have gone to get pedicures, 
but you need medical attention that the pedicures cannot provide. The Plan denied your request. The Plan says 
you do not have a diagnosis of diabetes or a foot at risk. Toenail trimming can be provided as a fee-for-service. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pre-
approve are routine foot care services. Based on this information, we decided that Medicare rules for coverage 
of podiatry care for debridement of toenails have not been met. Therefore, we decided that the Plan does not 
have to pre-approve podiatry care for debridement of toenails.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 25, 2022, to 
May 4, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.51, described as 
Sepsis due to Escherichia coli [E. coli], and secondary diagnosis code R65.20, described as severe sepsis. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that documentation does not support the billed code. Our physician 
reviewer found the enrollee is a 77-year-old male who was treated in the hospital. He presented with weakness, 
chills, urinary frequency in the setting of persistent urinary tract infection even with multiple rounds of 
antibiotics. He was reported to not eating or drinking well at home. The enrollee was treated with fluids and 
antibiotics. Following initial treatment, the notes described the creatinine, bilirubin, and platelets as normal, 
stable blood pressure, no hypoxia, and he was alert and oriented x 3. There was insufficient evidence of organ 
failure related to his infection due to a dysregulated response. Sepsis 3 criteria was not met. Therefore, the 
codes, A41.51 (Sepsis due to E. coli) and R65.20 (Severe sepsis) are each not supported by the documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 25, 2022, to May 4, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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's current medical condition requires an 
IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for an IRF admission. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83701 billed for date of service May 6, 2022.  
 
You asked the Plan to pay for procedure code 83701. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 83701 is bundled into 
payment for code 83722. 
 
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 83701 
is a column II code to column I code 83722 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we decided that 
the Plan does not have to pay for procedure code 83701 billed for date of service May 6, 2022.
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 1, 2022. 
 
You asked the Plan to pay for the billed services . You say that the test can eliminate the need for unnecessary 
antibiotics.  The Plan denied your request. The Plan says the request does not meet Medicare rules.  
 
The Plan must follow Medicare rules. Medicare rules say that panel testing is only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The records provided do not indicate that targeted panel testing was 
not appropriate. 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 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37253 and 37232 for date of service 
November 1, 2022. 
 
You asked the Plan to pay for procedure codes 37253 and 37232. 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 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) 
 
The CPT Code Manual definition of code 37232 is revascularization, endovascular, open or percutaneous, 
tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in 
addition to code for primary procedure). 
 
We find that CPT codes 37253 and 37232 are not supported in the medical record. Specifically, the operative 
report did not include documentation of an intravascular ultrasound (noncoronary vessel) during diagnostic 
evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each 
additional noncoronary vessel (Listed separately in addition to code for primary procedure); therefore, code 
37253 cannot be verified. 
 
The operative report did not include documentation of an open or percutaneous endovascular revascularization, 
of unilateral tibial/peroneal artery, for each additional vessel, with transluminal angioplasty (listed separately in 
addition to code for primary procedure); therefore, code 37232 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 37253 and 37232 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 37253 and 
37232 for date of service November 1, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF care was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that at the time of the appeal the enrollee did not require close follow-up with a physician or specialized rehabilitation nursing. The medical records show once the enrollee regained bladder function and the catheter was removed, no further rehabilitation was required.
The Plan is correct in this case. 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. Based on the medical records provided, whether an IRF stay would be beneficial is not of issue, the specific Medicare criteria must be met for the admission to be covered. In this case at the time of the appeal, the medical records do not show IRF admission was required for this enrollee. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that CardioMEMS is considered medically 
necessary. The Plan denied your request. The Plan says although CardioMEMS is approved by the Food and 
Drug Administration (FDA), this is not considered the standard of care at this time and shouldn't be approved 
outside of a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the CardioMEMS device is still not proven to be of significant improvement by any 
Randomized Clinical Trials (CRT) and still not recommended by the professional societies guidelines for Heart failure management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the criteria for an 
appropriate LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and does not require transfer 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
December 9, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like this to be 
reprocessed, as medical necessity has been met The Plan denied your request. The Plan says charges for or in 
connection with services or supplies that are, as determined by the Plan, considered to be experimental or 
investigational are excluded from coverage under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance; there is no additional allowance for supplies. 
 We looked at the file and Medicare rules. The record shows that the enrollee received a neuromuscular 
stimulator rental on December 9, 2022. Based on this information, we decided that Medicare rules for coverage 
of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for the electrical stimulator supplies (A4595) provided on December 9, 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 the enrollee is a constant fall risk and requires SNF 
services. The Plan denied your request. The Plan says the request 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 the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have 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/or skilled therapy on an inpatient basis in a 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 SNF care.