Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory assist device, bi-level pressure capability, 
without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist 
device with continuous positive airway pressure device) (E0470) provided June 28, 2022. 
 
You asked the Plan to pay for the respiratory assist device. You say that you have attached all medical records 
to prove medical necessity. Please kindly look into it and process the claim for payment. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for continued coverage. 
 
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 pay for the respiratory assist device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Per the reviewed medical records, the enrollee went for follow-up of dyspnea on 
exertion with a history of nocturnal hypoxia low diffusion capacity and mild COPD. The enrollee was noted as 
having shortness of breath with activity and has an occasional cough and has Barretts esophagus. Cough 
possibly related to reflux disease. The enrollee had significant desaturations on overnight oximeter testing and 
discussed the need for a sleep study. The enrollee agreed to a home sleep study. A compliance report from 
February 22, 2022, shows the enrollee has been 70% compliant. The only medical records or progress notes are 
from October 15, 2021. There are no current or up-to-date records showing a physician stating the benefit or 
continued need of the equipment as required by criteria. There are no updates on symptoms since use of the 
device has started. There is also no indication of a follow-up visit. The review has determined that the 
items/services at issue in this case are not medically reasonable or necessary and the medical records provided 
do not meet the medically necessary requirements listed in the LCD for Medicare coverage. 
 
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 respiratory assist device have not been met. Therefore, we decided that the 
Plan does not have to pay for the respiratory assist device, bi-level pressure capability, without backup rate 
feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous 
positive airway pressure device) (E0470) provided June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on July 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were submitted. The Plan 
denied your request. The Plan says the services were not billed as required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that CPT codes G0463 and G0402 were billed on the same date of service, with the same revenue 
code, without a condition code. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient 
hospital services provided on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition to lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5968). 
 
You asked the Plan to pre-approve the multiaxial ankle with swing phase active dorsiflexion feature. You say 
that the item was medically necessary. The Plan denied your request. The Plan says this item is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 multiaxial ankle with swing phase 
active dorsiflexion feature. Our reviewer says that this item is not medically necessary. Our physician reviewer 
found the L5968 is not a complete prosthetic foot and not medically necessary. The patient was approved for a 
K2 foot, L5968 exceeds the patient's medical nee  
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 multiaxial ankle with swing phase active dorsiflexion feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the addition to lower limb prosthesis, 
multiaxial ankle with swing phase active dorsiflexion feature (L5968).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane (J9264) and Atezolizumab (J0922). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 medication. Our physician reviewer 
found there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Abraxane (J9264) and Atezolizumab (J0922).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for IRF care have 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 that the available clinical documentation shows that you have complex functional 
impairments; however, there are no active medical issues specified. Additionally, no specific rehabilitation 
issues such as spasticity are mentioned in the documentation. Thus, the complexity of your documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve Vertiflex device. You say that the requested device is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested Vertiflex Superion device 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 Vertiflex device. Our reviewer says that 
the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous 
spacer at L3-4, in this case, 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex Superion device (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing for 22 or more drug classes (G0483) billed for 
date of service June 15, 2021. 
 
You asked the Plan to pay for drug testing. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says only 5 drug classes were tested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the available medical 
records do not support that the drug testing at issue was for 22 or more drug classes. Based on this information, 
we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for drug testing for 22 or more drug classes (G0483) billed for date of service June 
15, 2021.
Appeal type: Other
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 21, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but an administrative issue for claim errors. The Plan notes that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on January 18, 2022, rather than the billed date of service February 21, 2022. The date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected. In addition, the claim did not include the Medicare required DEX Z-Code or unique test identifier code.
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 could not be paid due to inconsistencies with the dates of service reported versus the specimen collection dates and the omission of a require test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the extraction of tooth #28 (D7210. We also decided that the Plan 
does not have to pre-approve a partial mandibular denture (D5214).  
 
You asked the Plan to pre-approve the extraction and denture. You say that tooth #28 has not been exhausted. 
The Plan has denied your request. The Plan says that your benefit for the requested items or services has 
already been exhausted. 
 
We decided that the Plan has to pre-approve the extraction of tooth #28 (D7210).  
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the extraction of tooth #28 was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve the extraction of tooth #28 (D7210).  
 
We also decided that the Plan does not have to pre-approve a partial mandibular denture (D5214). 
 
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, certain limitations apply. The record 
shows your benefit for a partial mandibular denture was exhausted on date of service November 18, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH can help the enrollee gain 
mobility with the goal of returning home. The Plan denied your request. The Plan says an LTACH admission is 
not medically, and the enrollee can receive the care they need in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intradialytic parenteral nutrition formula. 
 
You asked the Plan to pre-approve the nutritional formula. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be covered, the beneficiary 
must have a permanent impairment. 
 
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 nutritional formula. Our reviewer 
says that the requested nutritional formula is not medically necessary. Our physician reviewer found the 
provided records do not document the patient has a permanent condition that disrupts the ability to absorb 
nutrients. 
 
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 nutritional formula have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intradialytic parenteral nutrition formula.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. The Plan does not have to pre-approve tie-down 
hardware (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection and to pre-
approve tie-down hardware. You say that the requested items are a medical necessity for you. The Plan denied 
your request. The Plan says the request is not medically necessary or does not serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the provided records document that you have 4/5 
bilateral upper extremity strength and are independent with feeding, thus indicating that you have adequate 
upper extremity strength and function to operate the wheelchair's power options with their own switches. 
 
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 expandable controller with harness and electronic connection have not been 
met. The tie-down hardware does not serve a purpose that is primarily medical in nature. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) for a power wheelchair. The Plan does not have to pre-approve tie-down 
hardware (K0108) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 17003 and 11103 billed for date of service 
August 2, 2022. 
 
You asked the Plan to pay for procedure codes 17003 and 11103. The Plan denied your request. The Plan says 
payment for codes 17003 and 11103 is bundled into payment for code 17110.  
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 
17003 and 11103 are column II codes to column I code 17110. 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 17003 and 11103 billed for 
date of service August 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement services (procedure code 11720) provided 
to the enrollee on June 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is denied based on the information in the enrollee's claims history. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11720 is "Debridement of nail(s) by any method(s); 1 to 
5." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the servcies at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported CPT 11720 
and CPT 11719 Trimming of nondystrohic nails, any number for same date of service. CPT 11719 applies 
when the nails are healthy and void of defects from nutritional or metabolic abnormalities. 11720-11721 
includes trimming and shaping of the nails as well as debridement. You would not bill 11719 and 11720-21 together, and in this case modifier -59 is not appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for nail debridement services (procedure code 11720) provided to the enrollee on June 20, 2022.