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

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service April 21, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that these services were necessary and were 
ordered by the enrollee's physician. The Plan denied your request. The Plan says payment for code 0245U is 
bundled into payment for code 0018U. 
 
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, we have confirmed that code 0245U 
is a column II code to column I code 0018U with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 0245U billed for date of service April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiogram (CTA) of the aorta. 
 
You asked the Plan to pre-approve the CTA. You say that the CTA is medically necessary. The Plan denied 
your request. The Plan says medical records included do not include an ankle-brachial index. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 the CTA. Our reviewer says that the 
CTA of the aorta is not medically necessary. Our physician reviewer found that the enrollee has a history of 
peripheral vascular disease. A CTA of the aorta was requested. However, the provided documentation did not 
reveal reported symptoms of claudication or rest pain in the legs, decreased pulse strength, or a recent or prior 
ankle-brachial index measurement via physical examination showing sufficiently low circulation to warrant 
follow-up with advanced imaging. 
 
  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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography angiogram (CTA) of the aorta.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Regadenoson 0.1MG. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the medication. Our physician reviewer 
found the case file does not contain documentation that the enrollee in this case is unable to exercise, is 
incapable of at least moderate physical functioning, or has a disabling comorbidity. The documentation does 
not support that the Regadenoson is safe and effective 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 the 
medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Regadenoson 
0.1MG.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 25, 2022, billed with 
codes 81307, 81321, and 81345. 
 
You asked the Plan to pay for codes 81307, 81321, and 81345. 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 81307 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 81307 have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 25, 2022, 
billed with codes 81307, 81321, and 81345.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with enclosed frame and seat (E0144, E0156). 
 
You asked the Plan to pre-approve a walker with enclosed frame and seat. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a walker with enclosed frame and seat have not been met. Specifically, the medical necessity for a 
walker with an enclosed frame (E0144) has not been established. Therefore, if an enclosed frame walker is 
provided, it will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have 
to pre-approve a walker with enclosed frame and seat (E0144, E0156).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the accepted use of this drug requires that the enrollee is getting an 
aromatase inhibitor (for example: anastrozole, letrozole) as adjuvant therapy. The Plan states the enrollee is not 
receiving an aromatase inhibitor. The Plan states this was confirmed by communicating directly with the 
Provider's office and there was also an attempt to confirm another medically accepted indication for the drug, 
age-related osteoporosis, which would also allow for approval. The Plan states the provider was not able to 
confirm an Age-related osteoporosis diagnosis. The Plan states in the meantime, coverage was also requested 
for Xgeva and has been approved. The Plan states clinical records appear to indicate that Xgeva was also a 
requested drug. 
 
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 medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of estrogen receptor-positive and human epidermal 
growth factor receptor 2-negative breast cancer. The record does not indicate that the enrollee is receiving 
adjuvant aromatase inhibitor therapy or that the enrollee has age related osteoporosis. The FDA has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 1, 2021, 
through October 4, 2021, and billed with diagnosis codes E43 and Z68.31. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis codes E43 and Z68.31 is supported by the records. The Plan denied your request. The Plan 
says the documentation submitted does not support secondary diagnosis of E43 and Z68.31. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis codes E43- Unspecified severe 
protein-calorie malnutrition and Z68.31-Body mass index [BMI] 31.0-31.9, adult. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the documentation does not support diagnosis codes Z68.31 or E43. Our physician reviewer 
found the member was treated in the hospital with abdominal distention, anemia, liver cirrhosis, esophageal 
varices, ascites, and hypotension. The member's body mass index was measured at 31.3 (weight 218 at 70 
inches height) and previously recorded weight was 197, with an albumin at 1.6. There were no signs of muscle 
wasting, the member then was treated with paracentesis. The member had a calculated/estimated dry weight of 
28 which is not between 31-32 to justify the code Z68.31. Also, the member had no reported or documented 
significant weight loss, muscle wasting, or other clinical signs of severe protein malnutrition. Also, the low 
albumin was directly related to the members liver disease and not strictly poor dietary intake alone. Therefore, 
the code E43 is also not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 1, 2021, through October 4, 2021, and billed with diagnosis 
codes E43 and Z68.31.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Monovisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain related to osteoarthritis, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Euflexxa. The documentation does not support that Euflexxa would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided to the enrollee on May 17, 2021.
You asked the Plan to pay for the testing. You say that this is Medicare-covered testing that is reasonable and necessary for this enrollee. The Plan denied your request. The Plan says that this is Medicare-covered testing that is reasonable and necessary for this enrollee.
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 FoundationOne Liquid CDx testing provided to the enrollee on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 14, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 0245U is bundled into payment for 
code 0018U. 
 
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, we have confirmed that code 0245U 
is a column II code to column I code 0018U with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 0245U billed for date of service February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 18, 2022.
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 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 records submitted show
the specimen were collected on April 4, 2022, and it was received on April 5, 2022. The provider billed 81455
with date of service of April 18, 2022, and Place of Services (POS) 81. Medicare guidelines state the date of
service of the test must be the date the specimen was collected. The claim form listed the 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. Therefore, 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. Finally, this testing 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. In fact, the
diagnosis on the clinic note is "acute myeloid leukemia in remission". There is slso no documentation that the
enrollee had decided to seek further cancer treatment.
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 was not submitted with the correct POS code and the medical
records do not show the enrollee met the required criteria for this testing. 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 April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Emerg Auto-EmersiontherapyTM system mattress 
(E1399). 
 
You asked the Plan to pre-approve an Emerg Auto-EmersiontherapyTM system mattress. You say that the 
item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in 
nature. 
 
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 an Emerg Auto-EmersiontherapyTM system mattress 
(E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient rehabilitation is medically necessary. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
Your needs can be met at a lower level of care such as a skilled nursing facility, outpatient setting or home 
health care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endocrinology visit provided on October 17, 2022. 
 
You asked the Plan to pay for an endocrinology visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an endocrinology visit 
provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the services are not separately payable.  
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. We find that Train of Four Testing does not fit the 
criteria set by CMS and Insurance Carriers for CPT 95937. There is no separate code for Train of Four 
Monitoring, therefore, it would be inappropriate to bill the neuromuscular junction testing code for Train of 
Four Monitoring. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 95937 billed 
for date of service March 10, 2022.