Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus immunization (90715) and administration 
(90471), provided on October 26, 2021. 
 
You asked the Plan to pay for the tetanus immunization and administration. You say that the service is 
medically necessary. The Plan denied your request. The Plan says tetanus immunization is not covered as a 
preventative service. 
 In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus 
immunization and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus 
immunization and administration. Therefore, we decided that the Plan does not have to pay for the tetanus 
immunization (90715) and administration (90471), provided on October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 3, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services (92014, 92015) provided on 
September 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you were unaware that the provider was 
not contracted and needed prior authorization. You also say that this error was not caught sooner due to short 
staffing from the coronavirus (COVID-19). The Plan denied your request. The Plan says the rendering provider 
is a non-participating provider and there is no referring provider involved in these services. The Plan also says 
they did not authorize any services for this provider.  
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for ophthalmological services (92014, 92015) 
provided on September 20, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on September 10, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not 
enrolled in hospice on 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 6, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the test was requested by the referring 
provider, and it was medically necessary for the test. The Plan denied your request. The Plan says the referring 
and rendering providers are both out-of-network providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 27, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from September 25, 
2021, to October 24, 2021. 
 
You asked the Plan to pay for the home health care services. The Plan denied your request. The Plan says the 
RAP claim for these dates of service was not submitted until November 1, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, September 25, 2021. Therefore, we decided that 
the Plan does not have to pay for the home health care services provided from September 25, 2021, to October 
24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L4 selective nerve root injections. 
 
You asked the Plan to pre-approve bilateral L4 selective nerve root injections. The Plan denied your request. 
The Plan says epidural steroid injections are limited to a maximum of four (4) sessions per spinal region in a 
rolling twelve (12) month period. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs are limited to a maximum of four (4) sessions 
per spinal region in a rolling twelve (12) month period. 
 
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 bilateral L4 selective nerve root 
injection. Our reviewer says that bilateral L4 selective nerve root injections are not medically reasonable and 
necessary. Our physician reviewer found that the LCD restricts the number of epidural steroid injections to four 
in a rolling 12-month period. This request exceeds that limit. Therefore, at this time, the request is deemed 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 bilateral L4 selective nerve root injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bilateral L4 selective nerve root injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) report (93010) and critical care 
first hour (99291) provided on August 26, 2021. 
 
You asked the Plan to pay for the ECG and critical care. You say that these were significant separate 
procedures and are supported in the medical record. The Plan denied your request. The Plan says a National 
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between G0168 and 93010 and 
between G0168 and 99291. These PTP edits both have a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with these PTP code edits. These 
services were not billed as required by Medicare coding regulations. 
 
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 
93010 and 99291 are both column II codes to column I code G0168. These services have 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 the electrocardiogram (ECG) report 
(93010) and critical care first hour (99291) provided on August 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Remicade dose increase to 15 mg/kg. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has hidradenitis 
suppurativa. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for 
the enrollee's condition. The Medicare approved  drug compendia do contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The record provided indicates that the enrollee is 
improving but till has lesions and requires an increase dose. Medicare rules do not consider dose as a 
controlling factor unless included in an indication label. The requested dose is medically necessary and 
reasonable as defined by Medicare rules, for the enrollee's specific clinical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Remicade dose increase to 15 mg/kg.
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 enrollee requires IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says 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 Epogen. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is an 88-
year-old male with anemia with chronic kidney disease. The Plan requires a trial of drugs Aranesp and Retacrit 
before they will approve the requested drug, Epogen. In this case, the enrollee has not tried and failed the 
required drugs. Based on the medical records provided there is no indication that the plan's required drug(s) 
would likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.
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 you need IRF care. 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 you were admitted for lumbar spine surgery and confusion. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While you have a need for physical and/or occupational therapy, there is no documentation of a need 
for an intensive rehabilitation program. In conclusion, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was urgent to treat the enrollee and would like 
payment for the services provided. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no referral from an in-network provider or an approved authorization. 
Also, the service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on October 28, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the provider is enrolled and in-network with the 
Plan and the services should be paid. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no referral from an in-network provider or an approved authorization. 
Also, the service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 6, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. The Plan denied your request. The 
Plan says the clinical documentation fails to indicate that the member has any acute gastrointestinal symptoms 
at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is not medically reasonable and necessary. Our 
physician reviewer found Patient has a 5-pound weight loss since September 16, 2021. There are no abdominal 
symptoms. The medical necessity of CT abdomen and pelvis has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 13, 2021 and
billed under code G0483.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial.
The Plan requested a reopen and provided additional information. The Plan presented documentation to show
that this claim denied because the provider billed this service inappropriately. The Plan submitted specific
documentation of only 19 drug classes counted from the laboratory results received. Code G0483 is only used
when 22 or more classes were tested. The Plan states there is another more appropriate code for the services
provided and the provider billed the wrong 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, the Plan has
provided lab results to show less than 22 classes were tested, meaning this claim was not coded appropriately.
Medicare uses another code for testing resulting in less than 22 classes of drugs.
Therefore, we decided that the Plan does not have to pay drug testing provided to the enrollee on May 13,
2021, and billed under code G0483.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
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. 
 
The test at issue in this appeal, a molecular genetic screening, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on November 15, 2021.