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

 
We decided that the Plan does not have to pay for the laboratory services coded 81439, 81407, 81408, 81403, 
81404, 81405, and 81406 provided on October 19, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only 
covered for certain indications. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. This means codes 81439, 81407, and 81408 are not payable. In 
addition, we find that CPT codes 81403, 81404, 81405, and 81406 are not supported in the medical record. 
Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when 
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a 
laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting, place of service 11. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded 81439, 81407, 81408, 81403, 81404, 81405, and 81406 
provided on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda
(Pembrolizumab). The Maximus Physician Reviewer determined that the medication is medically necessary.
The reviewer found that Pembrolizumab is FDA-approved for the treatment of cervical cancer. Vulvar cancer
is treated like cervical cancer. There is not stated duration of therapy and although some experts may stop after
2 years, many will continue until toxicity or progression. "The service is reasonable and medically necessary."
The Plan argues that the recommended doses of Keytruda is 200 mg every 3 weeks until disease progression,
unacceptable toxicity, or up to 24 months in patients without disease progression. The Plan notes that the
enrollee in this case has received more than 24 months of treatment with the drug.
The Plan is correct in this case. The enrollee is a 55-year-old woman with a diagnosis of malignant neoplasm of
the vulva. After a recurrence of the malignancy, the enrollee was restarted on Keytruda in April 2019, and she
has maintained stable disease. Due to the positive response to Keytruda, the enrollee remained on the therapy.
The FDA-approved label for Keytruda states that the duration/timing of treatment for patients with locally
advanced or metastatic urothelial carcinoma is until disease progression, unacceptable toxicity, or up to 24
months. Therefore, Medicare coverage criteria were not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for physician services provided to the enrollee from March 30, 2020, to July 6, 2020.
You asked the Plan to pay this service. You say that you are eligible to accept Medicare payment as an out of network provider and these services should be covered by the Plan. The Plan denied your request. The Plan says that you are excluded or debarred from participation in State and Federal healthcare programs. The QIC upheld the Plans denial. After additional review of several cases from your office, we reopened the appeal.
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 Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services were met. The Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. The QIC performed a search of the List of Excluded Individuals and/or Entities from the Office of Inspector General and did not find that you were on this list. Without specific documentation from the Plan showing that you were excluded to receive Medicare reimbursement at the time the services were provided, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay for physician services provided to the enrollee from March 30, 2020, to July 6, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve CT colonography for the enrollee.
You asked the Plan to pre-approve this service. You say that a CT colonography is medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met. The QIC overturned the Plans
denial. The Plan requested a reopen and stated that the QIC did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for CT colonography.
The Physician Reviewer determined that the enrollee has recurrent GI blood loss and concern for
malignancy. In addition, the enrollee has ischemic heart disease and has concerns about anesthesia for
colonoscopy. Virtual colonoscopy is indicated in this case as patient has risks, that are reasonable to assume,
that makes her not wish to undergo anesthesia and colonoscopy. As this test is central to the enrollee's
diagnosis, it is reasonable and indicated since there is a reasonable chance patient will have malignancy and the
study will impact management. The Plan requested a reopen stating that the request for CT colonography was
not medically necessary, as the LCD coverage rules were not met. Our Medical Director reviewed the medical
records and the LCD. Our Medical Director says that the Plan is correct in this case. The enrollee did not have
an incomplete or failed standard colonoscopy, or a submucosal abnormality detected on standard colonoscopy,
and it was not determined that a standard colonoscopy could not be safely attempted. CT colonography is not
reimbursable when used initially as an alternative to a standard colonoscopy, even when performed for signs or
symptoms of disease, such as this enrollee had. Medicare coverage criteria are not met. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve
CT colonography for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 24, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 11. However, the records do not show that the specimen was collected in an office setting. This 
means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) 
provided on September 10, 2020. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for prevention of deep venous thrombosis or pulmonary embolism. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0673, E0675) provided on September 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (SCODI) service you received on May 29, 2021. 
 
You asked the Plan to waive the copayment for the SCODI service. You say that you should only have to pay 
your $43 copayment for a specialist office visit. The Plan denied your request. The Plan says you were charged 
this copayment correctly.  The Plan says that because the allowed amount for this service ($43.86) is less than 
your copayment obligation, you are responsible for the full allowed 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 $50 
copayment for diagnostic tests.  
 
Records show that on the date of service, you had an outpatient eye surgery in your ophthalmologist's office as well as a SCODI test.  You were charged a $45 copayment for the surgery and a $50 copayment for the SCODI 
test.  You are not disputing the $45 copayment for the surgery. Medicare allows plans to charge separate cost 
sharing for diagnostic tests. You have been asked to pay a $50 copayment for the SCODI service. The SCODI 
service falls within the diagnostic tests 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 the scanning computerized ophthalmic diagnostic imaging (SCODI) service you received on May 29, 2021.
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 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87591, 87640, 87641, 
87491, 87500, 87511, 87529, 87651, 87653, 87661, 87798, 87801) provided on June 7, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you have no knowledge of the enrollee's 
coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says this was 
a non-covered screening service. 
 The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (87150, 87481, 87591, 87640, 87641, 87491, 87500, 
87511, 87529, 87651, 87653, 87661, 87798, 87801) provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 8 acupuncture treatments. 
 
You asked the Plan to pre-approve the additional treatments. You say that this treatment has been helpful, and 
you believe that you should be allowed to continue getting this care. The Plan denied your request. The Plan 
says you are no longer receiving active acupuncture treatment. The Plan does not pay for maintenance therapy. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case. 
 
The records show that this treatment was not provided for CLBP, meaning that it is not covered by Medicare. 
We asked our physician reviewer to carefully review the case file and apply the relevant Plan policy rules to 
determine if the Plan was correct in denying the request to pre-approve the additional treatments. Our reviewer 
says that the criteria for coverage of additional acupuncture are not met in this case. Our physician reviewer 
found the record indicates that the enrollee has diabetic neuropathy. The relevant portion of the plan's criteria 
indicates that maintenance therapy in the absence of progressive clinical improvement is excluded from 
coverage. The record does not indicate continued progressive improvement. The requested service is 
maintenance therapy. The elements of the coverage criteria are not satisfied. 
 
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 additional treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 8 acupuncture treatments.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 4 home health skilled nursing visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 4 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. As such, the requested, ongoing, home health skilled nursing 
services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator provided on April 24, 2021. 
 
You asked the Plan to pay for a portable oxygen concentrator. You say that the requested item is needed when 
you walk. 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 only rented oxygen equipment is eligible for 
coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable oxygen concentrator have not been met. Specifically, in this case the item at issue has 
been purchased, not rented. Therefore, we decided that the Plan does not have to pay for a portable oxygen 
concentrator provided on April 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for severing adhesions (65875-59) provided on June 21, 2021. 
 
You asked the Plan to pay for severing adhesions. You say that this was billed correctly. The Plan denied your 
request. The Plan says this modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for severing adhesions Our reviewer says that 
the use of modifier -59 is not supported. Our physician reviewer found the documentation must support a 
different session, different procedure or surgery, different site or organ system, separate incision/excision, 
separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. The documentation in the operative note does not support 
the use of the -59 modifier 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 severing adhesions have not been met. Therefore, we decided that the Plan does 
not have to pay for severing adhesions (65875-59) provided on June 21, 2021.
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 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that this enrollee 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
simple extraction (D7140) provided on July 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and extraction. You say that these 
procedures should be covered. The Plan denied your request. The Plan says these services are not covered 
benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) and simple extraction (D7140) provided on July 15, 2021.