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

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
April 4, 2022. 
 
You asked the Plan to pay for procedure codes 88341 and 88342. You say that the patient had multiple exams 
on this date of service. The Plan denied your request. The Plan says payment for codes 88341 and 88342 is 
bundled into payment for code 88361. 
 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 codes 
88341 and 88342 are column II codes to column I code 88361. 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 codes 88341 and 88342 billed for 
date of service April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) additional ostomy pouches, drainable, with 
barrier attached (A4424). 
 
You asked the Plan to pre-approve additional ostomy pouches. You say that you need the additional supply 
because you are going through double the amount. You are getting the supply covered under your insurance but 
running out in half the time. The supplies are only lasting not even half the month and you have to go buy these 
on your own. The Plan denied your request. The Plan says the information provided does not show that your 
ostomy care needs are not able to be met with your current number of supplies. 
 The Plan must follow Medicare rules. Medicare rules say the quantity of ostomy supplies needed by a 
beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the 
skin surface surrounding the stoma. 
 
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 additional ostomy pouches. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that you are currently receiving 30 per month and 
allowable is 20 per month. Per the documentation, you had no issues when last seen in the office and no recent 
call ins from you. You have been scheduled for take down several times, however, you refuse to have a stress 
test which your primary care physician is requiring before the procedure. There is no specific clinical rationale 
for the requested additional ostomy pouches. The review has determined that the request for 30 additional 
ostomy pouches is not medically reasonable or necessary. The medical records submitted do not clearly 
document why the use of greater supplies is 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 additional ostomy pouches have not been met. Therefore, we decided that the 
Plan does not have to pre-approve thirty (30) additional ostomy pouches, drainable, with barrier attached 
(A4424).
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on October 25, 2021.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the records do not support the services billed. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the IRE medical review supports the Plans decision. The Plan stated that code 64625, radiofrequency ablation (RFA), nerves innervating the sacroiliac joint, with image guidance was billed in addition to 64640, destruction by neurolytic agent, other peripheral nerve or branch. Code 64625 is the only item denied. The operative report documents "radiofrequency ablation of left L3, L4, and dorsal primary ramus of L5 to denervate L4-5, L5-S1 facets." Also documented is a diagnosis of lumbosacral spondylosis. As the documentation does not support sacroiliac ablation, as also noted by the Maximus reviewer, there is a more appropriate code to describe the services provided.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Our physician reviewer found the procedure notes are for RFA of the lumbar facet joints and not the lateral sacral branches, which was the decision made by the Plan as well. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 13, 2022, to May 
23, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, for all enrollees receiving HH services in 2021 
whose services will continue in 2022, the HHA shall submit an NOA with a one-time, artificial 'admission' date 
corresponding to the "From" date of the first period of continuing care in 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, there is a discrepancy in the "From" date of 
service billed on the claim and the artificial admission date indicated on the submitted NOA. Therefore, we 
decided that the Plan does not have to pay for home health services provided from May 13, 2022, to May 23, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Truxima. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the use of Truxima for treatment of 
cryoglobulinemia with cryoglobulinemic vasculitis is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. It is not Food and Drug Administration-
approved for treatment of cryoglobulinemia with cryoglobulinemic vasculitis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen (J8499). 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that the enrollee has been stabilized 
on Hydrocodone over the past year and it has tremendously decreased their pain level. The Plan denied your 
request. The Plan says this drug is not covered for the enrollee condition by their Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone-
Acetaminophen (J8499).  
 
Benefits for Hydrocodone-Acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the requested kyphoplasty is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested kyphoplasty. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for the requested kyphoplasty. Our physician reviewer found the medical 
records document bone retropulsion that is a contraindication to kyphoplasty. The enrollee does not meet 
criteria in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87641, 88305 and 88312) 
provided on September 28, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says the provider who performed these services 
is ineligible to receive payment. 
 
The Plan must follow Medicare rules. The rules say that the Social Security Act provides the authority to 
Medicare to exclude various health care providers from receiving payment under Medicare. When an exclusion 
is imposed, no payment is made to anyone for any items or services in any capacity furnished, ordered, or 
prescribed by an excluded party under the Medicare. 
 The services at issue in this appeal were performed and signed off on by a provider who has had an exclusion 
imposed upon them by Medicare. Therefore, we decided that the Plan does not have to pay for laboratory 
services (87798, 87641, 88305 and 88312) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 16, 
2021. You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service May 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support 
the need for an inpatient hospital admission. The Plan denied your request. The Plan says there is no 
documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay. 
The Plan says that if the enrollee experiences any peri- or post-operative complications, reconsideration for 
inpatient level of care can be performed on concurrent review with updated information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at increased risk for peri-surgical complications requiring 
an inpatient stay.  There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that at the time of the 
request for an inpatient admission, the admitting physician reasonable expected that the patients necessary 
hospital care would span two midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness for an 
upgrade to an expandable controller (E2313) and an electronic connection between wheelchair controller and 2 
or more power seating system motors (E2311). 
 
 
 
 You asked the Plan to pre-approve power wheelchair accessories. You say that the power wheelchair with a 
power tilt and recline seating system should be approved so the enrollee can be provided with the appropriate 
medical equipment to meet his medical needs. The Plan denied your request. The Plan says although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair accessories. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found a group 3 power 
wheelchair can be covered if the medical necessity for a PWC is met and if the disorder causing the mobility 
limitation is a neurological condition, myopathy, or congenital skeletal deformity. The enrollee also must 
require a drive control interface, power tilt or a power recline seating system and if there has been a specialty 
evaluation that was performed by a licensed/certified medical professional, such as a physical or occupational 
therapist. An expandable controller is an electronic system that is capable of accommodating one or more 
additional features and can operate 3 or more powered seating options. In this case, the enrollee has a 
neurologic disorder with functional deficits. Criteria for a power wheelchair are met. The requested electrical 
accessories are not medically necessary as the enrollee does have use of the upper extremity and can operate 
and control the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377), a harness for an upgrade to an expandable 
controller (E2313) and an electronic connection between wheelchair controller and 2 or more power seating 
system motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286) and 
inhalation of nitrous oxide/analgesia (D9230). 
 
You asked the Plan to pre-approve an incisional biopsy and nitrous oxide/analgesia. You say that you cannot 
afford to pay for these services. The Plan denied your request. The Plan says an incisional biopsy of oral tissue 
is not covered under your benefit package. The Plan also says that the records do not clearly show why the 
inhalation of nitrous oxide/analgesia is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an incisional biopsy and nitrous 
oxide/analgesia have been met. Medical records related to the requested biopsy were not provided. We asked 
for these documents, but they were not received. Without this information, we cannot determine if the services 
requested are medically necessary. Therefore, we decided that the Plan does not have to pre-approve an 
incisional biopsy of oral tissue (D7286) and inhalation of nitrous oxide/analgesia (D9230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power elevating leg rests (E1012) and an expandable 
controller (E2377) with harness (E2313) for a power wheelchair. 
 
You asked the Plan to pre-approve power elevating leg rests and an expandable controller with harness. You 
say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan 
says the requested items are 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 power elevating leg rests and an 
expandable controller with harness. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee has a neurologic disorder 
with functional deficits. The documentation does not indicate that the enrollee has a medical condition that 
would meet criteria for power elevating leg rests. Furthermore, the requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power elevating leg rests and an expandable controller with harness have not 
been met. Therefore, we decided that the Plan does not have to pre-approve power elevating leg rests (E1012) 
and an expandable controller (E2377) with harness (E2313) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by 
an endodontist. 
 
You asked the Plan to pre-approve an evaluation. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a comprehensive oral evaluation is not covered when received by 
an endodontist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit when received by an endodontist. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation (D0150) provided by an endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intraosseous destruction of basivertebral nerve (Intracept procedure) (64628).

You asked the Plan to pre-approve Intracept procedure. You say that the enrollee has tried and failed conservative treatment without relief. You also say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the requested 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 Intracept procedure. Our reviewer says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Intracept is considered experimental. The reviewer found that additional research is needed. Therefore, the reviewer found that the requested procedure is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intraosseous destruction of basivertebral nerve (Intracept procedure) (64628).