Persius/hicric huggingface dataset:
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 admission is medically necessary. The 
Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 is no evidence that the enrollee requires services at the LTACH that are not 
currently available. The enrollee can remain at the current acute care hospital until such time as no acute 
services are required, then transfer/discharge to 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services for procedure codes 15734, 20704, 
20705, 20702, 20700, 15002, 15003, 20701, 15271, 20703, 97605, 15272, and 97606 for date of service May 
9, 2022, to May 11, 2022. 
 
You asked the Plan to pay for assistant surgeon services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 15271 and 15272. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon 
is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for assistant surgeon services have not been met. 
 
Codes 15734, 15002, 15003, 97606, and 97605 were billed with modifiers 82 and AS. The modifiers appended 
to these codes are similar as they are defined as assistant at surgery, however, the AS modifier is to be used 
when the services are provided by a physicians assistant (PA), nurse practitioner (NP), or clinical nurse 
specialist (CNS). Modifier 82 represents assistant at surgery by another physician when a qualified resident 
surgeon is not available to assist the primary surgeon. These modifiers should not be appended to the same 
service on the same line. 
 
In this case, we have confirmed that codes 20704, 20705, 20702, 20700, 20701, and 20703 are add-on codes 
and have not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for assistant surgeon services for procedure codes 
15734, 20704, 20705, 20702, 20700, 15002, 15003, 20701, 15271, 20703, 97605, 15272, and 97606 for date of 
service May 9, 2022, to May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on March 15, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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, the CPT Code Manual definition of code 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that 75 minutes 
were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99223) rendered on March 15, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to provide coverage for bioimpedance spectroscopy (BIS) services.

You asked the Plan to provide coverage for bioimpedance spectroscopy (BIS) services. The Plan denied your
request. The Plan says bioimpedance spectroscopy (BIS) services are not covered for lymphedema. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The NCCN Guidelines regarding Survivorship
Lymphedema does not recommend BIS in the management of lymphedema. The evidence in the medical
literature and the clinical documentation in this case are insufficient to support that bioimpedance spectroscopy
is medically reasonable and necessary for this enrollee. Therefore, we decided that the Plan does not have to
provide coverage for bioimpedance spectroscopy (BIS) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF services were
medically necessary. The Plan denied your request. The Plan says 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 the medical records show this enrollee's ability to participate in intensive
therapy was described as limited by the hospital physical therapist. The records show the enrollee refused to
attempt gait training due to pain to the right residual limb. It was also noted the stump was still healing and not
ready for prosthesis training.

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.
The medical records provided do not show at the time of the appeal, the enrollee could be expected to actively
participate in and to benefit from an intensive rehabilitation therapy program to include at least three hours of
therapy per day at least five days per week. Medicare rules for coverage of IRF care have not been met.
Therefore, we decided that the Plan does not have to provide coverage for 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided 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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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 
does not 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 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain their 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: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval.  
 
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 is medically stable as described above and does not need physical 
medicine and rehabilitation (PMR) physicians supervision 3 times a week in an IRF. There is no active 
medical complexity. No acute rehab nursing needs documented. At the current functional level, the enrollee 
needs routine physical therapy (PT), occupational therapy (OT) and does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. Document does not support necessity for admission to an IRF. The complexity of the enrollees medical, 
rehab, and nursing needs (combined complexity does not require acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. IRF admission is not necessary and is not reasonable. The 
enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled 
nursing facility (SNF).  
 
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 pre-approve bone growth stimulator. 
 
You asked the Plan to pre-approve bone growth stimulator. You say that it is medically necessary. The Plan 
denied your request. The Plan says it 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 bone growth stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it need 90 days for a nonunion to develop. Not enough time has passed for nonunion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone growth stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone growth stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 provided from February 
13, 2023, to February 14, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99233. You say that the medical records support the 
billing of code 99223 provided on February 13, 2023, and code 99233 provided on February 14, 2023. The 
Plan denied your request. The Plan says the medical records do not support the billing of code 99223 provided 
on February 13, 2023, and code 99233 provided on February 14, 2023. 
 
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 99223 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. The definition of code 99233 is Subsequent hospital 
inpatient or observation care, per day, for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 99223 and 99233. Our reviewer says that 
the medical records do not support the billing of code 99223 provided on February 13, 2023, and code 99233 
provided on February 14, 2023. Our reviewer found this case pertains to a male who presented to the hospital 
with acute appendicitis and on imaging was found to have a new lung cancer. Neither 99223 nor 99233 are 
supported based on high level of decision making or medically appropriate history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99223 and 99233 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99233 provided from February 13, 2023, to 
February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided May 2, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that please find appeal information that describes 
the medical necessity of the PrismRA test to inform consideration of payment. The Plan denied your request. 
The Plan says this test is not covered by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The DEX, Diagnostics Exchange database shows that PrismRA is not 
covered. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA testing (81479) 
provided May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87541, 87581, 87651, & 87798) 
provided on June 30, 2023.  
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87486, 87541, 87581, 87651, & 87798 are not supported in the medical record. 
Specifically, multiple unbundled codes were billed for a single panel. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services (87486, 87541, 87581, 87651, & 87798) provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Maximus overturned the Plans denial because the case file lacked a 2022 Plan contract. The Plan requested a
reopen and provided the required contract.

The Plan is correct in this case. 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 in this case is not a
network provider with the Plan. The Plan had network providers available who could have provided the
items/services at issue in this appeal.

The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to
pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services
provided to the enrollee out of network.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for percutaneous image-guided breast biopsy (19083).

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and
stated the issue was not the necessity of the service but an error with the diagnosis code reported on the claim.
The Plan notes the provider billed with diagnosis code N62 and Z76.82. These diagnosis codes do not full
under the coding and billing requirements shown in NCD 200.13.

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 reported diagnosis codes are not among those listed as covered on the NCD. Medicare rules for
coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for
percutaneous image-guided breast biopsy (19083).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 82306, 82607, 84443, 85025) provided 
on March 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80053, 82306, 82607, 84443, & 85025 are not supported in the medical record. 
Specifically, no lab order was provided for the tests billed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (80053, 82306, 82607, 84443, 85025) provided on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87635, 87502, 87503, 87486, 87541, 87581, 
87651, and 87798 provided on July 6, 2023. 
 
You asked the Plan to pay for procedure codes 87635, 87502, 87503, 87486, 87541, 87581, 87651, and 87798. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says the services are 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. 
 
We find that CPT codes 87635, 87502, 87503, 87486, 87541, 87581, 87651, and 87798 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for the 
services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87635, 87502, 87503, 
87486, 87541, 87581, 87651, and 87798 provided on July 6, 2023.