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

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 19, 2021.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that this claim was billed with a date of service and place of service inconsistent with Medicare rules governing laboratory services. The records submitted show the specimen were collected on date of service (DOS) November 19, 2021, and Place of Service (POS) 81. The claim listed the place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office contradicting the reasoning that the specimen was collected in a hospital.
The following three exceptions apply to the DOS policy for either a clinical laboratory test or the technical component of physician pathology service: A. DOS for Tests/Services Performed on Stored Specimens: B. DOS for Chemotherapy Sensitivity Tests/Services Performed on Live Tissue: C. DOS for Advanced Diagnostic Laboratory Tests and Molecular Pathology Tests: In the case of a molecular pathology test performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT under paragraph (1) of the definition of advanced diagnostic laboratory test in 42 CFR 414.502, the DOS must be the date the test was performed only if: - The test was performed following a hospital outpatient's discharge from the hospital outpatient department; - The specimen was collected from a hospital outpatient during an encounter (as both are defined in 42 CFR 410.2); - It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter; - The results of the test do not guide treatment provided during the hospital outpatient encounter; and - The test was reasonable and medically necessary for the treatment of an illness. The exceptions to the General Rule does not apply as the provider documented that the specimen was obtained by the laboratory directly. The test has not been cleared or approved by the FDA. As such, it does not meet the requirement of NCD 90.2. There is no documentation of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. There is no documentation that the enrollee had decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
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 claim submitted cannot be paid as billed due to issues with the dates of service billed, the POS code billed and the diagnosis code reported. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tumor Origin testing provided to the enrollee on April 4, 2022.
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan denied your request. The Plan says that the specimen was collected during surgery on March 3, 2022, during this inpatient admission, not 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 Tumor Origin testing provided to the enrollee on April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure 
(CPAP) device. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe obstructive 
sleep apnea (OSA) and has a CPAP at home. The device is one year old and the records do not document any 
problems with the device's function. The records do not support that the device is irreparably damaged. The 
replacement CPAP device is not reasonable or medically necessary at this time. 
 
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 a replacement continuous positive airway pressure (CPAP) device.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on November 23, 2021.
You asked the Plan to pay for this testing. 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 provided additional information. The Plan noted that the claim was billed with a date of service inconsistent with Medicare billing guidelines. The records show the specimen was collected on July 6, 2021. The test was stated to be ordered August 2, 2021. The billing laboratory did not receive the specimen until October 27, 2021. The provider billed code 81479 with a date of service of November 23, 2021, and a place of service (POS) code of 81, meaning the specimen was taken directly by the billing laboratory, however the medical records the specimen was collected in the hospital. Medicare billing criteria were not met.
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 discrepancies with the POS code reported and the dates of service reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted navigation (0055T). 
 
You asked the Plan to pre-approve computer-assisted navigation (0055T). You say that the requested 
computer-assisted navigation (0055T) for the approved total shoulder arthroplasty is medically necessary. The 
Plan denied your request. The Plan says the requested computer-assisted navigation (0055T) for the approved 
total shoulder arthroplasty 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 computer-assisted navigation (0055T). 
Our reviewer says that the requested computer-assisted navigation (0055T) for the approved total shoulder 
arthroplasty is not medically necessary. Our physician reviewer found the enrollee was being treated for 
primary osteoarthritis of the left shoulder. He presented with left shoulder pain. There is pain with movement. The exam reveals a decreased range of motion. Strength of the left shoulder is decreased at 4/5 in internal and 
external rotation and 3/5 in abduction and abducted external rotation. The health plan approved the total 
shoulder arthroplasty. However, there are limited/no large volume, long term/high quality clinical studies that 
confirm clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-
assisted surgery over standard surgical approaches in reverse total shoulder arthroplasty. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested computer-assisted navigation for the approved total shoulder 
arthroplasty, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted navigation (0055T) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve computer-assisted navigation (0055T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 6, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from February 6, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
February 6, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of February 6, 2023, forward. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment beyond February 6, 2023, as she was not a 
danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for 
the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from February 6, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 6, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump addition to a lower limb prosthesis 
(code L5782). 
 
You asked the Plan to pre-approve prosthesis vacuum pump. You say that this is needed to make the prosthetic 
operable and for the enrollee to enjoy better quality of life. The Plan denied your request. The Plan says this 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 prosthesis vacuum pump. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not support the contention that a vacuum pump system is medically 
reasonable and necessary 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 prosthesis vacuum pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a vacuum pump addition to a lower limb prosthesis (code L5782).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to high noble metal tooth #29 
(D6240), and retainer crown - porcelain fused to high noble metal tooth #30  (D6750). 
 
You asked the Plan to pre-approve the pontic - porcelain fused to high noble metal tooth #29 (D6240), and 
retainer crown - porcelain fused to high noble metal tooth #30  (D6750). The Plan denied your request. The 
Plan says these services do not meet the criteria for coverage 
 
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. The Plan covers the pontic - 
porcelain fused to high noble metal tooth #29 (D6240), and retainer crown - porcelain fused to high noble 
metal tooth #30  (D6750) when the services are medically necessary and reasonable.  
 
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 pontic - porcelain fused to high 
noble metal tooth #29 (D6240), and retainer crown - porcelain fused to high noble metal tooth #30  (D6750). 
Our reviewer says that the services requested are not medically necessary. Our physician reviewer found tooth 
#29 is missing and tooth #30 has drifted mesially into half the space left by tooth #29. Tooth #30 has a large 
existing restoration and would reasonably be used for an abutment for either a single unit crown or a cantilever 
bridge. Cantilever bridges are not usually a favored treatment, however where the missing space is very small, 
and the abutment is large and has solid bone support a cantilever bridge can be considered. Though not a 
necessity, the procedure would be reasonable in this situation. The Plan criteria for fixed bridges has not been 
met. The Plan provides for a bridge when the enrollee is missing only one upper front tooth or only two lower 
teeth. The two lower teeth must be next to each other and you also cannot be missing any of your back teeth. In 
this instance, tooth #'s 17, 19, 20 and 32 are missing. There are no missing anterior teeth. Given the Plan 
provisions the criteria has not been met for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic - porcelain fused to high noble metal tooth #29 (D6240), and retainer 
crown - porcelain fused to high noble metal tooth #30  (D6750) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pontic - porcelain fused to high noble metal tooth #29 (D6240), and 
retainer crown - porcelain fused to high noble metal tooth #30  (D6750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012), electric stimulation 
therapy (97014), therapeutic exercises (97110), office visits (99203, 99213), x-ray exam of the cervical spine 
(72040), and the x-ray exam of the lumbar spine (72100)  provided from October 11, 2021, through March 16, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction therapy (97012), electric stimulation therapy 
(97014), therapeutic exercises (97110), office visits (99203, 99213), x-ray exam of the cervical spine (72040), 
and the x-ray exam of the lumbar spine (72100) provided from October 11, 2021, through March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213) provided on June 20, 2022 and 
September 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits (99213) provided on June 20, 2022 and September 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim.  

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve a prostate artery embolization (PAE). You say that the requested prostate 
artery embolization (PAE) is medically necessary. The Plan denied your request. The Plan says the requested 
prostate artery embolization (PAE) 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 prostate artery embolization (PAE). Our 
reviewer says that the requested prostate artery embolization (PAE) is not medically necessary. Our physician 
reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat 
symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term 
safety and efficacy. The most recent American Urological Association (AUA) guidelines do not recommend 
this procedure outside of a clinical trial setting due to the heterogeneity in the available literature and safety 
concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, 
higher clinical failure rate compared with more traditional methods (eg, transurethral resection of the prostate 
[TURP]).  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization (PAE) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a prostate artery embolization (PAE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate (20939). You say that the requested bone marrow 
aspirate with the approved surgery is medically necessary. The Plan denied your request. The Plan says the 
requested bone marrow aspirate with the approved surgery 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 marrow aspirate (20939). Our 
reviewer says that the requested bone marrow aspirate with the approved surgery is not medically necessary. 
Our physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication. She presented with progressive pain, numbness, and tingling with occasional 
weakness. The exam reveals decreased strength at 4/5 in the bilateral ankle dorsiflexion and plantar flexion. Straight leg raise is positive bilaterally. X-rays are noted to show spondylolisthesis at L4-5 and L5-S1. 
However, there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested bone marrow aspirate with the approved surgery, in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate (20939) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim.  

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 2, 2022.