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

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device 
(Vertiflex procedure). 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure is recommended when conservative 
treatment has failed and as a safer alternative to a laminectomy or spinal fusion. The Plan denied your request. 
The Plan says the denial of authorization for this procedure is correct, because Vertiflex has not been found to 
be helpful for the enrollee's condition. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar stabilization device (Vertiflex procedure).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 10, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to the knee-shin system. 
 
You asked the Plan to pre-approve the requested item. You say that the code represents a billable feature. The 
Plan denied your request. The Plan says that the code cannot be requested separately. 
 
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. 
 
We looked at the file and the rules. We find that the Plan has agreed to approve code L5828. The requested 
code L5845 is an addition code that is able to be billed separately. The DME PDAC states that the assignment 
of a code to a product should in no way be construed as an approval. In as much, there is no rule or 
documentation that a product, and its codes, that is not listed should be construed as non-covered. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pre-approve an addition to the knee-shin system.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the requested College Park Capital Knee prosthetic with code 
L5845 (in addition to approved codes L5828, L5850, and L5925). 
 
You asked the Plan to pre-approve the additional code. You say that the requested knee is coded with L5845. 
This is medically necessary and should be approved. The Plan denied your request. The Plan says that the code 
L5845 cannot be used for this prosthetic component and is unbundled. Although the manufacturer uses code 
L5845 for this knee, neither the manufacturer nor the vendor has the authority to assign this code to the 
requested knee. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted a valid citation or cogent argument in support of 
denial of the approval of code L5845. Though the Plan indicates that manufacturer-suggested coding is not 
binding or official, the Plan did not make any specific argument as to why L5845 does not describe the 
function of the requested knee. We find that, in absence of any specific citation disallowing the use of code 
L5845, the Plan's denial has not been substantiated. Therefore, we decided that the Plan has to pre-approve the 
requested College Park Capital Knee prosthetic with code L5845 (in addition to approved codes L5828, L5850, 
and L5925).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgery to be performed at an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network surgical services. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that performed the 
services the enrollee needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the surgery to be performed at an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L3-4 decompression and stabilization procedure. 
 
You asked the Plan to pre-approve an L3-4 decompression and stabilization procedure. You say that the 
requested L3-4 decompression and stabilization procedure is medically necessary. The Plan denied your 
request. The Plan says the requested L3-4 decompression and stabilization procedure is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve L3-4 decompression and stabilization 
procedure. Our reviewer says that the requested L3-4 decompression and stabilization procedure is not 
medically necessary. Our physician reviewer found criteria for spinal L3-4 fusion and decompression are not 
met. The records show that this enrollee is an everyday smoker which is a contraindication to L3-4 fusion and 
decompression surgery. There must be proof of smoking cessation for at least 6 weeks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an L3-4 decompression and stabilization procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an L3-4 decompression and stabilization 
procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) 
provided January 24, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this test was 
medically necessary and used to help determine treatment options. The Plan denied your request. The Plan says 
that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making 
in the clinical management of the patient and will be denied automatically as not medically necessary 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case the Plan denied the targeted genomic sequence analysis panel on the 
basis that it is non-covered by Medicare. Specifically, the Plan stated that Medicare Local Coverage Article: 
Billing and Coding: Molecular Pathology Procedures (A56199) states that genetic testing procedures 
submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of 
the patient and will be denied automatically as not medically necessary. We reviewed the article and found 
that this exclusion applies to codes listed in Group 3 in the article. Code 81455 is not currently listed in Group 
3. Thus, this exclusion does not apply to the service at issue. Therefore, we decided that the Plan has to pay for 
the targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and 
RNA analysis when performed, 51 or greater genes (81455) provided January 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee-shin system addition. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says that the 
code cannot be used for the specific named prosthetic component. 
 
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. 
 
We looked at the file and the rules. There is no specific rule that disqualifies L5845 from the requested knee 
system. The Local Coverage Article shows that code L5845 must be used in combination for a knee system, 
that includes code L5828, which the Plan has agreed to pre-approve. The DME PDAC does not specifically 
identify the Mauch knee, or the list of codes associated with it. Furthermore, the documentation does not show 
that the provider has specifically requested a Mauch knee. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we 
decided that the Plan has to pre-approve a knee-shin system addition.  
 
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 procedure code 99497 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that the service provided was medically 
necessary and the claim should be processed for payment. The Plan denied your request. The Plan says 
payment for code 99497 is bundled into payment for code 99223. 
  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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service March 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous transcatheter closure of the left atrial 
appendage (Watchman procedure) (CPT code 33340) and inpatient hospital admission. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is at extreme high risk of bleeding 
and cannot go off anticoagulation until this procedure is completed and also, the enrollee should be able to have 
the procedure as they meet all the elements listed on the documentation. The Plan denied your request. The 
Plan says the enrollee's request is not medically necessary because the enrollee's facility is not enrolled in an 
appropriate registry. 
 
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 services. Our physician reviewer 
found the enrollee must be enrolled and participate in a prospective, national, audited registry that: 1) 
consecutively enrolls LAAC patients, and, 2) tracks annual outcomes for each patient for a period of at least 4 
years from the time of the LAAC. Records do not show that the facility is enrolled in such a registry. As such, 
guidelines would not support implantation of a LAAC in this setting. In summary, LAAC placement would not 
be considered reasonable or medically necessary in this enrollee's 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous transcatheter closure of the left atrial appendage (Watchman procedure) 
(CPT code 33340) and inpatient hospital admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexccom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexccom G6 CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexccom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexccom G6 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive any of the cost share specialist services provided on July 8, 2021.
You asked the Plan to waive some of this cost share. You say that you did not believe this cost share is correct.
The Plan denied your request. The Plan says this cost share was applied based on the services provided.
Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not
apply the correct contract language. The Plan stated that the records show you were provided several services
including training and directions on how to use the splint and was shown exercises to do with your thumb. The
provider is listed as an Emergency Medicine Specialist. The Evidence of Coverage explains there will be a $20
copayment for Specialist Physician Office Visits.
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 (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay $20 copayment for specialist 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 $20 copayment charged for specialist services provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 10, 2021, billed with 
codes 81286, 81410, 81411, 81413 and 8141. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are supported as billed. The 
Plan denied your request. The Plan says these services were not billed in accordance with Medicare rules. 
 
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 
June 10, 2021, billed with codes 81286, 81410, 81411, 81413 and 8141.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided on October 7, 2021 under the Medicare benefit.
You asked the Plan for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information.
Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to pay for these services under the Medicare benefit.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99453) 
provided on December 1, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee does not have 
any other primary payer active during the date of service in this case. The Plan denied your request. The Plan 
says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B 
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan 
also says it is the providers responsibility to verify the enrollees coverage before rendering services and to 
know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99453) 
provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
(87798, 87481) provided January 26, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that urinalysis is the standard of care for urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine polymerase chain reaction (PCR) panel testing (87798, 87481) provided January 26, 2022.