Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) 
provided on September 16, 2022. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents (D4381). You say that this was just 
a cleaning and should be covered. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the localized delivery of antimicrobial 
agents (D4381) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the localized delivery of antimicrobial agents (D4381) provided on September 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on August 31, 2021.
You asked the Plan to pay for the testing services. You say that the testing is fundamental in guiding the enrollee's treatment. The Plan denied your request. The Plan says that the specimen was collected during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified (87798) provided August 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing this denial on medical 
necessity and request reconsideration of coverage and payment. The Plan denied your request. The Plan says 
charges for or in connection with services or supplies that are considered to be experimental or investigational 
are excluded from coverage under the Plan. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a history of autoimmune hepatitis, 
undifferentiated connective tissue disease, hypertension, diabetes mellitus, and gastroesophageal reflux disease 
(GERD). Deoxyribonucleic acid sequences specific for a pathogen of interest can be isolated from a variety of 
microorganisms. Such DNA probes can be exploited to detect infectious agents directly in infected patient 
material despite the presence of large numbers of other organisms and host DNA. There was no specific 
clinical rationale for the nucleic acid (DNA or RNA), not otherwise specified 87798. The review has 
determined that the items are not medically necessary or reasonable. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified 
(87798) provided August 16, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ontruzant. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has breast cancer. She has 
not tried and failed the Plan's required drugs, Kanjinti or Trazimera. The records do not show that the required 
drugs would be contraindicated or less effective; therefore, Ontruzant is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ontruzant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and panoramic x-rays 
(D0330) provided on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you had a limit on these 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 14, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and panoramic x-rays 
(D0330) provided on July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) 
(87633) provided August 15, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you disagree with this determination and 
request an appeal for this medically necessary visit The Plan denied your request. The Plan says service does 
not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or National 
Coverage Determination (NCD). 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that there was no specific clinical rationale for the obtained 
study. The review has determined that the items/services at issue in this were not case 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) (87633) provided 
August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), the electrical 
connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) 
and harness (E2313). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you are requesting reconsideration of 
the medical necessity of all the components of this K0861 required by the enrollee to meet his medical, 
functional and mobility needs throughout the day in his home and other environments. The Plan denied your 
request. The Plan says although there are three requested power options (tilt, recline and elevating leg rests), 
there is not a medical need to control these power options through the joystick. The Plan also says a seat 
elevator does not serve a primary medical purpose and is statutorily non-covered. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require a ventilator, or non-proportional input devices (e.g., sip 
and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee has power options on the wheelchair, but the enrollee does not 
need to control the power options through a joystick. The enrollee's upper extremity function supports that he 
can control any power options through their own switches. The power seat elevation system does not service a 
medical purpose and is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (E2300), the electrical connection between the 
wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve repeat RFA. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
 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 repeat RFA. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have chronic neck pain without radiation. You have had RFA of the Right 
cervical facets on May 2, 2022, and then the Left on June 17, 2022. It has not been 12 months since the prior 
RFA and there is a frequency limitation of two RFA sessions per six-month period. This request exceeds this 
limit. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial dentures (D5213). 
 
You asked the Plan to pre-approve the upper partial denture (D5213). You say that you badly need the dentures 
because it is difficult to eat. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 25, 2019. 
Therefore, we decided that the Plan does not have to pre-approve the upper partial dentures (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150-59 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 87150-59. You say that this service was necessary and is 
supported as billed. The Plan denied your request. The Plan says this service is not supported in the medical 
record. 
 
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 87150 is culture typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate each organism probed for 
reimbursement consideration. Healthcare plan denied payment for unbundled service. 
 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 87150-59. Our reviewer says that this service 
is not supported by the records provided. Our reviewer found the laboratory report did not include 
documentation of culture typing; identification by nucleic acid probe, amplified probe technique, per culture or 
isolate. The report cannot be cited as this procedure was not found in laboratory report. Since code 87150 
cannot be verified, the 59 modifier also cannot be verified to show this service as a separate distinct service. 
 
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 87150-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87150-59 billed for date of service June 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service June 13, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that you disagree 
with the denial. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, 88360 and 88381 have a Professional/Technical indicator of 1. This means 
that CPT codes 88341, 88342, 88360 and 88381 have both a professional and technical component. In this 
case, CPT codes 88341, 88342, 88360 and 88381 have not been billed with an appropriate modifier to indicate 
the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service June 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of four PT 
visits. 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 medically necessary outpatient 
therapy. 
 
 
  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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found additional visits are not medically necessary or reasonable based on 
the review of documentation by the physical therapist. The requested therapy is generally accepted as a specific 
and effective therapy for the enrollees neck and shoulder pain. However, the most recent documentation 
indicated that the enrollee was performing arts and crafts, cooking, cleaning, and all other movements dont 
hurt. The enrollee can continue with a home exercise program and does not require the service of a skilled 
physical therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel weak and IRF care is necessary for you to 
get stronger and better. The Plan denied your request. The Plan says the requested 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 you continue to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement. However, the documentation does not support that you would meet criteria for admission to an IRF. There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours per week, under the supervision of a physician with at least 3 
visits per week to regain or maintain your functional status. Our reviewer found you 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucynta. 
 
You asked the Plan to pre-approve Nucynta. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
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 Nucynta.  
 
 
 Benefits for Nucynta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before Prolia can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record shows no evidence of fracture. The record 
does not show a trial of the plan preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) electronic connection 
between wheelchair controller and 2 or more power seating system motors (E2311) harness for upgrade to 
expandable controller (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please review for appeal. The Plan 
denied your request. The Plan says the upgraded electronics exceeds the enrollee's needs. 
 
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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require a ventilator, or non-proportional input devices (e.g., sip 
and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee has power options on the wheelchair, but does not need to control 
the power options through a joystick. The enrollee's upper extremity strength and function support that the 
enrollee can control any power options through their own switches. The requested items exceed the enrollee's 
medical needs and does not meet Medicare medical necessity criteria 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) electronic connection between wheelchair 
controller and 2 or more power seating system motors (E2311) harness for upgrade to expandable controller 
(E2313).