Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the physical therapy visits are medically 
necessary. The Plan denied your request. The Plan says your function has improved, and you can manage your 
knee problem with a home exercise program. 
 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 therapy visits. 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 that the enrollee has had extensive prior therapy and the remaining 
deficits can be met with the eight approved therapy sessions. The physician reviewer also says the enrollee can 
transition to a home exercise program. In this case, the remaining 10 therapy sessions are not 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 2, 2021 billed 
with codes 81402, 81400, 81321, 81314, 81311, 81310, 81293, 81276, 81275, 81270, 81235, 81210, 81201, 
81173, 81121, and 81120. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed correctly per 
Medicare coding regulations. 
 
 
 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 2, 2021 billed with codes 81402, 81400, 81321, 81314, 81311, 81310, 81293, 81276, 81275, 81270, 
81235, 81210, 81201, 81173, 81121, and 81120.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home physical therapy (PT) services (G0151). 
 
You asked the Plan to pre-approve home PT services. You say that you have been on palliative care because 
you have displaced disks. You also say you have a caretaker who helps you walk, and are not sure why the 
therapy was denied. The Plan denied your request. The Plan says you do not meet criteria for home health PT 
visits. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home PT services. Our reviewer says 
that home physical therapy (PT) services are not reasonable and necessary. Our physician reviewer found you 
do not have documented home health PT needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home PT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home physical therapy (PT) services (G0151).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve a myocardial perfusion imaging. You say that the enrollee has Hypertension 
with a history of Carotid disease. You also say that the enrollee's last cardiovascular testing was performed in 
2018, and they cannot do a treadmill stress test. The Plan denied your request. The Plan says this request does 
not meet the Medicare or health plan coverage criteria. 
 
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 a myocardial perfusion imaging. Our 
reviewer says that the myocardial perfusion imaging is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has no cardiac symptoms. The enrollees pre-test 
probability for an abnormal test is low and there is no documentation that their electrocardiogram (ECG) shows 
an uninterpretable pattern. Our reviewer found there is no evidence provided that would support the need for 
radionuclide stress testing. Our physician reviewer also found that there is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing in this enrollees clinical management. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a myocardial perfusion imaging (78452).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test kit purchased on January 28, 2022.
You asked the Plan to pay for this test kit. You say that the Plan should pay for this testing. The Plan denied
your request. The Plan says coverage for this testing was not available on the date of purchase. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
contract language.
The Plan is correct in this case. Medicare rules state health plans had the choice as to whether they would cover
home testing kits supplementally. The Plan contract addendum states supplemental benefits for home COVID-
19 test kits began on February 1, 2022.
You purchased this home test kit before this benefit began. Therefore, we decided that the Plan does not have
to pay for a home COVID-19 test kit purchased on January 28, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test purchased on January 17, 2022.
You asked the Plan to pay for this test. You say that this test should be covered by the Plan. The Plan denied
your request. The Plan says home tests were not covered at the time of purchase. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. Medicare gave health Plans the option to cover home COVID-19 testing as a
supplemental benefit. The Plan did not begin coverage for home test kits until February 1, 2022. This test was
purchased prior to the beginning of this benefit. Therefore, we decided that the Plan does not have to pay for a
home COVID-19 test purchased on January 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the soft tissue of the 
neck (70490). 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says the medical 
necessity criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that computed tomography (CT) scans are covered 
only when they are 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 a CT scan. Our reviewer says that a CT 
scan is not reasonable and necessary. Our physician reviewer found the issue in this case does not appear to be 
related to the airway but rather the possibility of esophageal in origin. Hence the notion that laryngoscopy is 
necessary prior to a neck CT does not appear to be appropriate. Our reviewer found that the possibility of 
esophageal or swallowing issues has not been addressed by imaging. Our physician reviewer also found that 
the clinical notes indicate that the enrollee's thyroid is not the likely cause of symptoms, and no adenopathy is 
mentioned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) of the soft tissue of the neck (70490).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 4, 2021, billed with 
codes 81162, 81314, 81317, 81334, 81407, 81408, 81435, and 81479. 
 
You asked the Plan to pay for the laboratory services billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met.  
 
Medicare rules also say that claims submitted where the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 2. 
 
In this case, the MUE for CPT code 81162 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
81162 have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 4, 2021, 
billed with codes 81162, 81314, 81317, 81334, 81407, 81408, 81435, and 81479.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity for the enrollee. 
 
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not have any stated contraindications to the preferred products. 
 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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary. The Plan requires a trial of Forteo before they will approve the 
requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation 
provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy 
criteria for Evenity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima for the enrollee. 
 
You asked the Plan to pre-approve Truxima. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Truxima. Our reviewer says that 
Truxima is not medically reasonable and necessary. The enrollee has not tried Rituxan (rituximab), Ruxience 
(rituximab-pvvr) or Riabni (rituximab-arrx). The plan's required drugs would not likely be less effective and/or 
likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not 
meet step therapy criteria for Truxima. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve sterile gloves. 
 
You asked the Plan to pre-approve sterile gloves. You say that these are needed for dressing changes due to 
wound care. The Plan denied your request. The Plan says that the denial of authorization for these supplies is 
correct, because the enrollee does not have end-stage renal disease (ESRD). 
 
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. You say that these gloves are needed for wound care. The Plan denied because 
the enrollee does not have ESRD. However, as the enrollee does not have ESRD, any coverage restrictions 
applied to ESRD-related care are not pertinent to this request. The Plan did not provide any other rationale or 
evidence to support a denial of authorization. Therefore, the Plan has not shown that its decision to deny 
authorization for these supplies is correct or justified according to Medicare rules. Therefore, we decided that 
the Plan has to pre-approve sterile gloves.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the venography services (75825-59) provided on October 25, 2021. 
 
You asked the Plan to pay for the venography services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says code 75825-59 is not supported in the 
documentation and is not payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 venography services Our reviewer says 
that the documentation does not support payment for CPT code 75825-59. Our physician reviewer found the 
operative report does not include enough documentation to confirm venography, caval, inferior with 
serialography, radiological supervision and interpretation has been performed. The operative report documents 
that "We catheterized the infrarenal inferior vena cava. We performed a venogram of the infrarenal inferior 
vena cava."  In this case, the procedure does not describe contrast medium injection to visualize and evaluate 
abnormalities (per National Correct Coding Initiative guidelines). Therefore, this procedure code cannot be 
verified as performed. 
 
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 venography services have not been met. Therefore, we decided that the Plan 
does not have to pay for the venography services (75825-59) provided on October 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an at home COVID-19 test purchased January 11, 2022.
You asked the Plan to pay for this home COVID-19 test. You say that this test should be covered by the Plan.
The Plan denied your request. The Plan says this test is covered by Original Medicare. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan states that a letter was sent to all enrollees indicating that coverage for up to 8 home tests would be
provided beginning on February 1, 2022. This purchase does not qualify for that benefit.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that starting January 15, 2022,
enrollees with a health plan can go online, or to a pharmacy or store to purchase an at-home over the counter
COVID-19 diagnostic test at no cost, either through reimbursement or free of charge through their insurance.
The plans may cover this as a supplemental benefit starting January 15, 2022.
The Plan communicated to enrollees that this testing would be covered supplementally free of charge after
February 1, 2022. Keep in mind Medicare is not requiring Plans to cover this as a benefit.
You purchased this test on January 11, 2022, which is prior to the January 15, 2022, coverage for Medicare and
prior to the February 1, 2022, coverage for your health plan for reimbursement for home testing. Therefore, we
decided that the Plan does not have to pay for an at home COVID-19 test purchased January 11, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at a lower level of 
care such as in a skilled nursing facility, at home with home health services or at home with outpatient therapy. 
 
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 while you may benefit from continued physical therapy and occupational 
therapy, your needs can be safely provided in an alternate setting such as in a skilled nursing facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nyvepria for the enrollee. 
 
You asked the Plan to pre-approve Nyvepria. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Nyvepria. Our reviewer says that 
Nyvepria is not medically reasonable and necessary. The Plan requires a trial two of the following drugs: 
Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb) or Udenyca (pegfilgrastim-cbqv) before they will 
approve Nyvepria. The patient has tried and failed Udenyca (pegfilgrastim-cbqv) but there is no indication that 
the patient has tried and failed Neulasta (pegfilgrastim) or Fulphila (pegfilgrastim-jmdb). There is no indication 
that Neulasta (pegfilgrastim) or Fulphila (pegfilgrastim-jmdb) would likely be less effective and/or likely have 
adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step 
therapy criteria for Nyvepria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nyvepria have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nyvepria for the enrollee.