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

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has cervical and 
lumbar radiculopathy. 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive genomic profile (CGP) testing (81479). We decided 
that the Plan does not have to pay for the pathology services (88341, 88342 and 88360).  
 
You asked the Plan to pay for laboratory/pathology services (81479, 88341, 88342 and 88360) provided on 
September 1, 2022. You say that these services were medically necessary and were reported appropriately. The 
Plan says that the comprehensive profile cannot be covered as it includes the FANCC and BLM genes which 
are non-covered. In addition, the pathology codes are included in the facility payment and are not separately 
payable as they are missing the 26 modifier. 
 
We decided that the Plan has to pay for the comprehensive genomic profile (CGP) testing (81479).  
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Although this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDX contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the CGP profile have been met. Therefore, we decided that the Plan has to pay for the 
comprehensive genomic profile (CGP) testing (81479).  
 
We also decided that the Plan does not have to pay for the pathology services (88341, 88342 and 88360). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure codes 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for the 
pathology services (88341, 88342 and 88360). 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $285 copayment charged for outpatient endoscopy services provided on August 27,2021.
You asked the Plan to waive this copayment. You say that you were told these services would be covered by the Plan. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial because the case file lacked the appropriate Plan contract. The Plan requested a reopen and provided the required contract.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay a $285 copayment for outpatient hospital or outpatient surgical services. 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 $285 copayment charged for outpatient endoscopy services provided on August 27, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the travel allowance services coded P9603 provided on July 
12, 2022. 
 
You asked the Plan to pay for the travel allowance services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
 We find that CPT code P9603 is not supported in the medical record. Specifically, the medical records do not 
include sufficient detail to support travel allowance. Based on this information, we decided that Medicare rules 
for coverage of the travel allowance services have not been met. Therefore, we decided that the Plan does not 
have to pay for the travel allowance services coded P9603 provided on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex device placement surgery. 
 
You asked the Plan to pre-approve a vertiflex device placement surgery. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertiflex device placement surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on January 27, 2022 and billed under code 80307.
You asked the Plan to pay for code 80307. 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 stated that Maximus did not apply the correct criteria. The Plan provided additional information to show code 80307 (1 Unit) remains not supported. Only one drug test within the presumptive drug class and one drug test within the definitive drug class per date of service and per enrollee is covered. The claim history shows presumptive and or definitive services were submitted by another provider for this date of service; therefore, it cannot be separately reimbursed.
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, code 80307 was billed inappropriately based on Medicare coding guidelines. Medicare rules for coverage of code 80307. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on January 27, 2022 and billed under code 80307.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided from February 9, 2022, to 
February 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
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 use of code 99233 is 
not supported by the records provided. Our reviewer found that this code requires two out of these three key 
components: a detailed interval history, a detailed examination and medical decision making of high 
complexity. In this case, the medical records submitted did not support a detailed interval history, a detailed 
examination and medical decision making of high complexity for the date of service in question. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99233) provided from February 9, 2022, to February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Our physician reviewer found that the enrollee is undergoing 
treatment of lung cancer and is reported to experience "spikes and drops" with the blood glucose. However, the 
patient is only taking metformin once a day rather than the twice a day recommended and would not requiring 
intensive care management, is not at a high risk of hospitalization but rather requires better outpatient 
management. She does not have an active diagnosis that is life-threatening or significantly limiting her overall 
health and function based on the provided documentation. Based on this information, we decided that Medicare 
rules for coverage of SSBCI benefits have not been met. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently receiving long term care in a nursing home. The enrollee is 
not intubated/ventilated. There is no evidence that the enrollee requires the level of care provided at a LTACH. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency medical transportation (NEMT). 
 You asked the Plan to pre-approve NEMT. The Plan denied your request. The Plan says a current PCS form 
was not submitted by the provider, and only an expired PCS form can be found which expired on February 1, 
2023. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the completion of a PCS form is completed prior to the 
services being arranged or provided to determine the appropriate level of service. 
 
We looked at your request, the records in the case file, and the rules. A current completes PCS form was not 
provided. The record shows that the Plan reached out to your provider three times to obtain a completed PCS 
form, but it was not received. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
non-emergency medical transportation (NEMT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GeneSight pharmacogenomics testing. 
 
You asked the Plan to pre-approve GeneSight testing. You say that this testing is medically necessary and 
reasonable. The Plan denied your request. The Plan says the records do not show that the provider is considering medications which require a multi-gene panel since there is no documented plan for treatment, nor 
whether medication treatment is medically necessary for your condition over non-pharmaceutical treatments. 
 
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 GeneSight testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have a history of asthma and back pain. Your provider has indicated that you 
have been experiencing difficulty with sleeping, and Ambien is no longer effective. You are being treated with 
medications for weight loss including phentermine. The provider has indicated that you have tried Cymbalta, 
Pristiq, and Effexor in the past and that they were stopped due to being ineffective. The provider has not 
indicated the need for treatment with a specific medication, but rather that you would like to proceed with 
GeneSight testing to guide therapy. In this case, the records do not show that the provider is considering 
medications which require a multi-gene panel since the plan for treatment is not documented, nor whether 
medication treatment is medically necessary for your condition over non-pharmaceutical treatments. The 
review has determined that the requested testing is 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 GeneSight testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve GeneSight pharmacogenomics testing.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on March 7, 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 stated that Maximus did not apply the correct billing criteria.
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 codes. In this case the claim was not submitted with the required unique testing identifier code or Dex-Z code. 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 March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on July 13, 
2022. 
 
You asked the Plan to pay for the back brace. You say that this should be reprocessed and paid. The Plan 
denied your request. The Plan says the submitted documentation does not include mention of ordering or 
utilizing durable medical equipment for treatment to support the code at issue. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The medical records provided do not adequately document the need for a brace. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 17, 2022, by an  
out-of-network provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on November 17, 2022, by an  
out-of-network provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that guidelines prove this helps the enrollee's condition. 
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 may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Erbitux. Our reviewer says that the 
enrollee meets criteria for Erbitux. Our physician reviewer found Erbitux is Food & Drug Administration 
(FDA) approved for the enrollee's diagnosis. Treatment of metastatic colorectal cancer in adults with a BRAF 
V600E mutation as detected by an approved test after prior therapy. The enrollee has received several prior 
lines of therapy and cetuximab is considered an option for right-sided tumors, but not as initial treatment. The 
records support that this drug is safe and effective and otherwise 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 Erbitux have been met. Therefore, we decided that the Plan has to pre-approve 
use of Erbitux.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87491, 87563, 87640, 87653 and 
87798) provided on August 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were reported correctly. The Plan 
denied your request. The Plan says the primary diagnosis code reported on this claim is not appropriate as a 
primary diagnosis, as it is a manifestation code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that manifestation codes have a "code first" note and should be sequenced after an appropriate 
etiology code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the only/primary diagnosis reported on this 
claim is F05 (delirium due to known physiological condition). Diagnosis code F05 has a "code first" note, 
instructing providers to report the underlying physiological condition before code F05. This means that it is not appropriate to use this diagnosis code alone or as a primary diagnosis. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87481, 87491, 87563, 87640, 87653 and 87798) provided on August 
16, 2022.