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

 
We decided that the Plan does not have to pre-approve Kerecis Omega3, per sq cm (Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega3, per sq cm. 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 Chronic Wounds are defined as wounds that do not 
respond to standard wound treatment for at least a 30-day period during organized comprehensive conservative 
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 Kerecis Omega3, per sq cm. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the request is not 
medically necessary because the records do not show that the enrollee has a chronic wound that had a failed 
response. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis Omega3, per sq cm have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Kerecis Omega3, per sq cm (Q4158).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. The Plan denied your request. The Plan says that this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit medical records with the case file from the contracted 
provider. After outreach to the Plan for medical records, the Plan submitted the same pre-certification request 
that was submitted with the case file, which was not signed by a provider. Without supporting records from the 
contracted provider, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pre-
approve Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services have not been 
met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a home ventilator (E0466) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices [E0673 and E0675], 
provided on June 6, 2022. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare when the place of service is an ambulatory surgical center. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression devices [E0673 and E0675], provided on 
June 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 medically necessary. Our physician reviewer found the use of SBRT is an appropriate standard 
of care in the absence of widespread metastases in this enrollee. The advantages of SBRT are to allow dose 
escalation while minimizing the volume of normal tissue exposed to high dose radiation. The services are 
reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy (SBRT).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay a higher amount for transplant-related transportation provided on 
February 4, 2022. 
 
You asked the Plan to pay a higher amount for transplant-related transportation. You say that the millage 
reimbursement should be higher. The Plan denied your request. The Plan says this was paid appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which a Medicare 
Advantage (MA) plan provides transplant services at a more distant location, the MA plan must provide 
reasonable transportation for the enrollee and a companion to the distant facility 
 
We looked at the file and Medicare rules. The file shows that the Plan has made payment for reasonable 
transportation to the transplant facility. Based on this information, we decided that Medicare rules for 
additional payment for transplant-related transportation have not been met. Therefore, we decided that the Plan 
does not have to pay a higher amount for transplant-related transportation provided on February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that all requested accessories are medically 
necessary to meet the enrollee's current needs. The Plan denied your request. The Plan says a non-medical 
feature that is intended for use outside the home is not considered durable medical equipment (DME) and is 
statutorily not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit kit (K0108).
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 for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was medically necessary. The Plan denied your request. The Plan says at the time of the appeal, the enrollee still required an inpatient hospital level of care. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan reiterated that at the time of the appeal, the enrollee was not ready for discharge from inpatient hospital care due to acute urinary retention which had not been resolved.
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 enrollee must have the ability to participate in the level of therapy provided by an IRF.
Based on the medical records provided, the enrollee did not meet these criteria. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 hours of neuropsychological testing evaluation 
services by physician or other qualified health care professional. 
 
You asked the Plan to pre-approve an additional hour of neuropsychological testing services. You say that the 
services are medically necessary. The Plan denied your request. The Plan says an additional hour of testing 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 an additional hour of 
neuropsychological testing services. Our reviewer says that the requested additional hour of testing services is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
documentation does not support the medical necessity of an additional hour of testing. The reviewer found that this type of testing is typically done in 8-hour intervals. The reviewer found that an additional hour would 
exceed the enrollee's needs. Therefore, the reviewer found that the request for an additional hour of testing 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 an additional hour of neuropsychological testing services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 9 hours of neuropsychological testing 
evaluation services by physician or other qualified health care professional.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the xT genetic testing provided to the enrollee on April 7, 2022.
You asked the Plan to pay for the xT genetic testing. You say that this is medically necessary testing. 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 xT genetic testing provided
to the enrollee on April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on July 21, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you should 
not have to pay for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for other Medicare-covered diagnostic radiology services, which includes magnetic resonance 
imaging (MRI). 
 
You have been asked to pay a $250 copayment for magnetic resonance imaging (MRI). This item/service falls 
within the other Medicare-covered diagnostic radiology services, which includes magnetic resonance imaging 
(MRI) benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for magnetic resonance imaging 
(MRI) provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 7, 2021.
You asked the Plan to pay for this testing. You say that the Plan should pay this claim. The Plan denied your
request. The Plan says the 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 rules governing laboratory services. The records submitted show
that specimen (tube set) was collected on May 27, 2022. The specimen was received on May 28, 2022.
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. There is no documentation that the sample was taken in the laboratory. The difference in date of
collection and date received confirms that the was not collected directly by the laboratory. Medicare guidance
states no payment shall be made to any provider of services or other person under this part unless there has
been furnished such information as may be necessary in order to determine the amounts due such provider or
other person under this part for the period with respect to which the amounts are being paid or for any prior
period. The date of service for a clinical laboratory test or the technical component of physician pathology
service must be the date the specimen was collected with 3 exceptions. None of the exceptions apply in
this case as the provider billed with POS 81. If an independent lab bills for services, the place where the sample
was taken is shown. POS code 81 is used to describe samples taken by the laboratory directly which is not
correct in this case.
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 could
not be paid due to issues with the POS code billed 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 June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 22, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the test was ordered by an independent clinic and not a hospital outpatient clinic. The requisition states "I will arrange for specimen shipping". On the claim the test was billed with place of service (POS) 81, which contradicts the assertion that the specimen was obtained during a hospital outpatient encounter. The exception to the general rule for date of service would not apply in this case. would not apply in this case. would not apply in this case. The claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimen (tube set) was collected on February 15, 2022. The specimen was received on February 16, 2022. 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. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. The claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimen (tube set) was collected on February 15, 2022. The specimen was received on February 16, 2022. Place of service (POS) code 81 indicates the specimen was taken by the billing laboratory, 81, Independent Laboratory, independent of an institution or a physician's office. There is no documentation that the sample was taken in the billing laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory.
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 cannot be paid as billed due to issues with the POS code billed and the dates of service reported Medicare rules for coverage of this services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that this is necessary for the enrollee to be 
able to get in and out of his wheelchair properly without risk of causing injury to himself. The Plan denied your 
request. The Plan says the request for a power seat elevation is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 63047) provided to the enrollee on 
May 3, 2021. 
 
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 that the denied code is not supported in the records submitted. 
 
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 63047 is "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 
lumbar." 
 
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 supported by the medical records. Our reviewer found that the procedure details cite the superior 
lamina and some of the inferior laminae were removed at this involved space. The transverse processes were 
exposed and the facets of the levels to be fused were stripped of soft tissue. The spinous process above and 
below was trimmed enough to be able to place the cages. Decompression started at the L4-5 level. The facets at 
that level were removed and a facet osteotomy performed to allow movement of this level. The superior lamina 
and some of the inferior lamina were removed at this involved space. The spinous process above and below 
were trimmed enough to be able to place the cages. The bone was removed with a combination of drill and 
Kerrisons and ronguers. Ligamentum flavum was also removed to decompression the underlying compressed 
nerve roots. Therefore, the records do support that CPT 63047: laminectomy, facetectomy, and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or 
lateral recess stenosis]), single vertebral segment, lumbar was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 63047) provided to the enrollee on May 3, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.