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 enrollee needs this care to regain 
strength,endurance and mobility. The Plan denied your request. The Plan says the enrollee's current medical 
needs do not require IRF care,services can be provided in an different setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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 validity testing billed with code 83789 for date(s) of service 
June 21, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 15, 2023, billed with 
codes 81408, 81407, 81406, 81161, 81405, 81404, 81403 and 81400. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
May 15, 2023, billed with codes 81408, 81407, 81406, 81161, 81405, 81404, 81403 and 81400.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x21). 
 
You asked the Plan to pre-approve home health services. You say that this is medically 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 the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has chronic lower extremity swelling and wounds. The wounds appear to be multiple and superficial. Wound 
care treatment has been underway for nearly a year, without apparent improvement. The enrollee appears able 
to attend wound care clinic appointments. There may or may not be an available caregiver to provide dressing 
change in the absence of the skilled nurse. Consequently, the ongoing services of a home health skilled nurse 
do not appear to be medically necessary or reasonable, especially at the frequency requested.  
 
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 skilled nursing (G0299 x21).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehab facility (IRF) services. 
 
You asked the Plan to pre-approve IRF services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 We looked at the file and Medicare rules. The Plan requested an AOR but did not receive it. Without the AOR 
we cannot determine if the person who sent the appeal in has appeal rights. Based on this information, we 
decided that there is insufficient information in the record to determine if the services are medically necessary. 
Therefore, we decided that the Plan does not have to pre-approve inpatient rehab facility (IRF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an IRF to improve 
overall function mobility and safety prior to returning home with their family. The Plan denied your request. 
The Plan says an IRF admission 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 laboratory services (88305, 88177, 88173) provided on 
February 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this claim should be paid. The Plan denied 
your request. The Plan says this claim was not filed timely. 
 
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 claim for the laboratory services was not filed until April 25, 2023. 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 the laboratory services (88305, 88177, 88173) provided on 
February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic controller (E0651) and full leg garments 
(E0667). 
 
You asked the Plan to pre-approve intermittent limb compression device. 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 state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found this enrollee's 
lymphedema appears to be improving with current medical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic controller (E0651) and full leg garments 
(E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation services (99152). 
 
You asked the Plan to pre-approve moderate sedation services. 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 follows Medicare rules. Medicare rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions. 
 
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 moderate sedation services. Our 
reviewer says that the services are not medically necessary Our physician reviewer found there is no clinical 
rationale for the requested level of sedation for a facet joint injection. The review has determined that you do not meet the coverage criteria detailed in the LCD. The anesthesia services 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 v have not been met. Therefore, we decided that the Plan does not have to pre-
approve moderate sedation services (99152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single power option 
(tilt) and accessories. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with single power option. You say that you are 
bedridden and unable to walk. You also say that your doctor recommended this power wheelchair. The Plan 
denied your request. The Plan says this requested power wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with single power option 
may be covered when certain criteria are met. 
 
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 Group 2 power wheelchair with single 
power option. Our reviewer says that the request for a Group 2 power wheelchair with single power option is 
not medically necessary. Our physician reviewer found the provided records do not support that you are high 
risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. The reviewer found that 
the records do not document that you perform bladder self-catheterization or that you have increased muscle 
tone or spasticity to meet criteria for the power tilt and thus the single power option base. Therefore, the 
reviewer found that the request for a Group 2 power wheelchair with single power option is not medically 
reasonable or necessary. As the requested wheelchair base does not meet Medicare coverage criteria, the 
requested accessories are not covered either. 
 
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 Group 2 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single 
power option (tilt) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with an out-of-network specialist. 
 
You asked the Plan to pre-approve specialist services. You say that you need to see a urologist for a very 
specific and delicate procedure. You also say that you need this surgery as soon as possible. The Plan denied 
your request. The Plan says there are network providers available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 specialist services. Our reviewer says 
that the requested office visits with an out-of-network specialist are not medically necessary. Our physician 
reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet your 
medical needs through referral to a network urologist who is able to perform bladder augmentation if 
necessary. The records do not indicate anything unique about your condition that that would make it medically 
necessary for you to see the requested out-of-network provider. The reviewer also found that the Plan has 
shown that they have in-network providers who meet the Standards of Care required for treatment of your 
condition. Therefore, the reviewer found that the requested office visits with an out-of-network specialist 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 specialist services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve office visits with an out-of-network specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair (K0001) and elevating legrest (K0195). 
 
You asked the Plan to pay for a wheelchair and elevating legrest. You say that the items are medically 
necessary. The Plan denied your request. The Plan says there is insufficient information to determine medical 
necessity of these items. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a wheelchair and elevating legrest have 
been met. No medical records were submitted for review. Therefore, we decided that the Plan does not have to 
pay for a wheelchair (K0001) and elevating legrest (K0195).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065 billed for date of service June 23, 
2023.  
 
You asked the Plan to pay for procedure code 77065. You say that 77065 should be paid as billed because it is 
supported in the record and was not a bundled service. The Plan denied your request. The Plan says payment 
for code 77065 is bundled into payment for code 77066. 
 
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 77065 is a column II code to column I code 77066 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 77065 billed for date of service June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee for October 9, 2022.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the provider has been submitting claims for A4595 Electrical stimulator supplies, 2 lead, per month since January 9, 2022. The provider did not submit any evidence that they have been contacting the member before shipping additional supplies. The provider has also been shipping supplies above the maximum quantity allowed by Medicare.
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, based on the records provided, the claims submitted do not meet the required Medicare criteria for payment of these supplies. Therefore, we decided that the Plan does not have to pay for , Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee for October 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on October 9, 2022.
You asked the Plan to pay for the electrodes. You say that code A4595 is an accepted procedure code. The Plan denied your request. The Plan says that the proof of delivery is not valid. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The provider is billing the units in excess of the Medicare allowed amount. Therefore, this claim was denied correctly.
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, the provider is billing for supplies separately for rented equipment, which is not allowed. The provider is also billing in excess of the normal units allowed by the billing guidelines. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on October 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 24, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve the medication. You say that Prolia is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Prolia have not been met.  
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 the medication. Our physician reviewer 
found the Plan requires a trial of oral bisphosphonates and zoledronic acid before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drugs. 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. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Prolia (J0897).