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

 
We decided that the Plan does not have to pre-approve treatment with Cosela (J1448). 
 
You asked the Plan to pre-approve Cosela. You say that the requested treatment is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not been 
met because the drug has been prescribed for an off-label and medically unsupported use. 
 
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 Cosela. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Cosela is not FDA-approved for the enrollees diagnosis. The use is not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cosela have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Cosela (J1448).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 16, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not call the ambulance yourself and were okay after receiving the EpiPen injection. You also say that the medic 
did not want you to go to the emergency room because of the long waits and COVID exposure. The Plan 
denied your request. The Plan says the ambulance benefit is a transport benefit, if no transport of a Medicare 
beneficiary occurs, then there is no Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 16, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that the Emergency Medical Services spoke with you about transport options, but you 
resisted to be transported because you were complaint free. Therefore, we decided that the Plan does not have 
to pay for the ambulance response and treatment with no transport (A0998) provided on September 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee from
December 16, 2020, to December 17, 2020.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information regarding their denial. The Plan requested a reopen and provided additional
information.
First, the Plan stated that that a modification was required for code 99291, 71045 for date of service December
16, 2020, and code 93306 for date of service December 17, 2020. These codes will now be paid by the Plan.
The Plan confirms the denial of codes 96365-XU, 96366-XU x 11, for date of service December 16, 2020. The
Plan states the start and stop times for required for medication administration are not supported. The
documentation submitted does not support the route and time the infusions were administered.
In addition, code 96372 has a status indicator of Q1, meaning "Packaged Services Subject to Separate Payment
under OPPS Payment Criteria."
This means Q1 services are packaged if they appear on the same claim with services with a status indicator of
"S" (Significant Procedure, not discounted when multiple), "T" (significant procedure, multiple reduction
applies, or V (Clinic or emergency department visit). Code 96372 is packaged into the Emergency
RoomGeneral 450 rev code payment (CPT 99291).
The Plan states for codes 84484 and 84484-91 x 2, Revenue code 250 x 10 units, Revenue code 272 x 2 units,
Revenue code 762 x 10 units for date of service 12/16/2020 and CPT Codes 80061, Revenue code 250 x 16
units, and Revenue code 762 x 18 units, payment for these services are packaged into the payment that has
been issued for Revenue Code 450 (CPT 99291).
The Plan also states for code 80048, 83036, 84145, 84443, 85025, 94640, 93005, 93005-XU, these services
have a status indicator of "N", meaning payment for these items and services are packaged into the APC Rates.
Meaning, payment for these services is already packaged into payment for other services, including outliers.
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. While the Plan has now
revised payment for some of the services billed, the remaining denied codes were separately billed in error as
based on the Medicare billing guidelines. Therefore, we decided that the Plan does not have to pay for
emergency room services provided to the enrollee from December 16, 2020, to December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you need this device. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because you are not using insulin 
shots 3 or more times per day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the criteria for an admission to an IRF has not been met. 
 
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 is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extracorporeal photopheresis provided to the enrollee on
August 20, 2021.
You asked the Plan to pay for these services. You say that this treatment was medically necessary. The Plan
denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare regulations.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Extracorporeal
Photopheresis (ECP). The MAXIMUS Physician Reviewer determined that bronchiolitis obliterans (BOS) is a
rare disorder without clear guidelines for treatment and that the service was determined to be medically
reasonable and necessary in this case.
The Plan requested a reopen and states ECP is a Medicare benefit for BOS only following lung allograft
transplantation, and only when the ECP is provided under a clinical research study.
Our Medical Director has concluded that the Plan is correct in this case. NCD 110.4 states that Medicare
provides coverage for ECP for the treatment of BOS following lung allograft transplantation only when the
ECP is provided under a clinical research study that meets specific conditions. All other indications for ECP
not listed in the NCD are non-covered. Consequently, ECP treatment for the enrollee's condition of BOS
resulting from Castleman disease is non-covered by Medicare.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this services have not been met. Therefore, we decided that the Plan does not
have to pre-approve extracorporeal photopheresis provided to the enrollee on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro device (L8702). 
 
You asked the Plan to pre-approve the MyoPro device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is 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 the MyoPro device. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current clinical guidelines designate robotic therapy to be of "uncertain utility compared with 
dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
Although records from the device manufacturer/vendor argue medical necessity of the requested device, no 
records from the enrollees actual treating provider clarify why the requested device is the most appropriate 
treatment for the enrollees condition. In addition, provided records document the enrollee has a left shoulder 
subluxation and left upper extremity spasticity which may be contraindications to use of the requested device. 
 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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MyoPro device (L8702).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography scan services provided to the enrollee
on May 30, 2020 and billed under code 70450.
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 these services were previously paid. Maximus overturned the Plans denial for lack of
proof of payment in the file. The Plan requested a reopen and provided additional claim documentation. The
Plan documentation shows code 70496, was reimbursed on June 16, 2020, under a separate claim. Code 70450
has a bundled relationship with code 70496. National Correct Coding Initiative (NCCI) procedure to procedure
(PTP) edits have been assigned to either Column One/Column Two Correct Coding edit. CPT code 70496 is
listed and Column One and CPT code 70450 is listed in Column Two. This claim has not been billed with an
appropriate modifier to bypass this edit when billed together on the same claim. Therefore, the Medicare billing
criteria are not met.
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 this claim
cannot be paid as billed due to the omission of the appropriate modifier that would allow payment. Based on
this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for computed tomography scan services provided to
the enrollee on May 30, 2020 and billed under code 70450.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lumbar facet 
joint (64635, 64636). 
 
You asked the Plan to pre-approve a radiofrequency ablation of the lumbar facet joint. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
medical necessity rules for coverage for the requested services have not been met. 
 
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 radiofrequency ablation of the lumbar 
facet joint. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the coverage criteria clearly state the need for 2 sets of 
diagnostic MBBs which produce 80% or greater pain relief. Only one set of MBBs is documented in the 
available medical records. 
 
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 radiofrequency ablation of the lumbar facet joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the 
lumbar facet joint (64635, 64636).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 23, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you needed immediate help. You say that 
you called the ambulance.  You also say that after a few minutes your blood sugar was back to normal. The 
Plan denied your request. The Plan says since there was no transported provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 23, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Additionally, the record shows that you refused transport to the hospital. Therefore, we decided that the Plan 
does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on November 
23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
November 3, 2021. 
 You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that this is the only time that you 
have ever received this service. The Plan denied your request. The Plan says this service is a covered benefit, 
but you have exceeded the limits set in the subscriber agreement. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA) for beneficiaries who meet the following criteria listed in the 
Rules section above.  
 
We looked at the file and Medicare rules. The contract says that abdominal aortic aneurysm screening is 
limited to a one-time screening ultrasound for people at risk. The record shows that you received an ultrasound 
of the abdominal aorta (76706) on January 10, 2019 and your abdominal aortic aneurysm screening benefit has 
been exhausted. Based on this information, we decided that Medicare rules for coverage of the ultrasound of 
the abdominal aorta have not been met. Therefore, we decided that the Plan does not have to pay for the 
ultrasound of the abdominal aorta (76706) provided on November 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on December 6, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance was 
by doctor's orders and you had no choice. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $295 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $295 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services 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 
ambulance transportation services provided on December 6, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a catheter ablation procedure. 
 
You asked the Plan to pre-approve a catheter ablation. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for 
coverage of the requested services have not been met. 
 
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 a catheter ablation. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that recent randomized clinical studies have supported the role of catheter ablation for the 
treatment of typical atrial flutter as an acceptable first-line alternative to medications in the treatment of 
patients with the enrollee's type of arrhythmia. This is, in part, because of the high likelihood of success, 
without recurrences, compared with catheter ablation of atrial fibrillation, for example. Clinical guidelines have 
been modified to reflect the findings of the new studies. Therefore, electrophysiologic evaluation and catheter 
ablation of typical atrial flutter would be considered reasonable in the 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 catheter ablation have been met. Therefore, we decided that the Plan has to 
pre-approve a catheter ablation procedure.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 2, 
2022. 
 You asked the Plan to pay for procedure code 70496. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service January 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) and lead wires (A4557) provided on August 24, 2021. 
 
  You asked the Plan to pay for the ambulance response and treatment with no transport and lead wires. You say 
that you had two seizures on August 24, 2021, and the ambulance was called because you have heart problems 
that lead to seizures. The Plan denied your request. The Plan says Medicare does not have a benefit for 
ambulance services rendered when there is no ambulance transportation. The Plan also says that lead wires are 
not paid separately. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The rules also say that payment under the fee schedule for ambulance services precludes a 
separate payment for items and services furnished under the ambulance benefit. 
 
The ambulance company did not provide transport services on August 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Supplies are also not separately payable. Therefore, we decided that the Plan does not have to pay for the 
ambulance response and treatment with no transport (A0998) and lead wires (A4557) provided on August 24, 
2021.