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

 
We decided that the Plan has to pay for the lab testing services provided on March 15, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing identifies clinically actionable 
biomarkers in the enrollee's tumor. The Plan denied your request. The Plan says that the testing is not 
considered standard of care. 
 
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 testing services. Our physician reviewer 
found that the enrollee has metastatic neoplasm. A biopsy was taken from the porta hepatis node. The primary 
origin is unknown. According to the National Comprehensive Cancer Network (NCCN) guidelines for occult 
malignancy shows that next generation sequencing is endorsed to look for actional mutation. Therefore, the 
testing was medically 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 the testing services have been met. Therefore, we decided that the Plan has to 
pay for the lab testing services provided on March 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. 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. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has severe chronic obstructive 
pulmonary disease (COPD). She does not have a diagnosis for which the HFCWOD is covered by Medicare, namely, cystic fibrosis, broncheictasis, or neuromuscular disease. There is insufficient evidence that this device 
is effective in the treatment of COPD. The services are therefore not reasonable or medically 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment and provide reimbursement for the surgical
services provided from February 24, 2022, through June 10, 2022.
You asked the Plan to reduce the copayment and provide reimbursement for the surgical services. You say that
the procedure was only about 10 minutes and was not surgical. The Plan denied your request. The Plan says
this cost sharing was charged correctly.
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 $295
copayment for each Medicare-covered outpatient hospital facility visit.
You have been asked to pay a $295 copayment for the surgical services for each date of service. This
item/service falls within the Medicare-covered outpatient hospital facility visit 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 reduce the copayment and provide reimbursement for the surgical services provided
from February 24, 2022, through June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Flex-Walk advanced K3 functional level ankle foot system.
You asked the Plan to provide coverage for this equipment. You say that this equipment 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 a Flex-Walk advanced K3 functional level ankle foot system. The Maximus Physician Reviewer determined that the enrollee has a history of right below the knee amputation previously using a K2 prosthesis. In this case, the clinical records show that patient is now a K3 level ambulator requiring a prosthesis that would assist with ambulation on variable terrain and steps. Therefore, the K3 foot and ankle system prosthetics (L5981, L5988) are medically necessary.
The Plan requested a reopen and stated that the medical records show your specific functional activity level is not documented. The Plan states there is no compelling clinical justification for the requested replacement prosthesis with a K3 functional level ankle-foot component. Neither your physician nor any involved skilled therapist documented the need for a replacement prosthesis with a K3 functional level ankle-foot component. The request for this replacement prosthesis with a K3 functional level ankle-foot component exceeds your needs and does not meet the Medicare criteria of reasonable and necessary. Our Medical Director has concluded that the Plan is correct in this case. The available clinical notes do not support the upgrade replacement to a K3 functional level ankle-foot component as represented by codes L5981 and L5988. 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 request have not been met. Therefore, we decided that the Plan does not have to provide coverage for a Flex-Walk advanced K3 functional level ankle foot system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex procedure. 
 
You asked the Plan to pre-approve the Coflex procedure. You say that the enrollee has tried conservative 
therapies with no success. You say that the requested procedure is approved by the Food and Drug 
Administration (FDA) and is supported by the records provided. The Plan denied your request. The Plan says 
there are currently no clinical indications for the requested technology. The Plan says that Coflex has not been 
shown to be safe and effective for spinal fusion surgery. 
 
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 the Coflex procedure. Our reviewer 
says that the Coflex procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has tried conservative therapies with no success. You say that the requested 
procedure is approved by the Food and Drug Administration (FDA) and is supported by the records provided. 
 
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 Coflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Coflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is not an agreement to 
include this in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 5, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that you require medical assessment by skilled nursing, 
and you have a progressive neurodegenerative disease with functional impairments and would benefit from 
skilled therapy. Evaluating therapists and primary team notes that you would benefit from outpatient therapy or 
home with supervision and there is no specific recommendation for frequency of skilled nursing. From a 
practical standpoint, you do not require daily skilled services in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 you are appealing the denial of 
authorization for LTACH admission. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital or a skilled nursing facility. You have improved medically and can receive further care at the current 
acute care hospital or a lower level of care when deemed appropriate. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for noninvasive ear or pulse oximetry for oxygen saturation; by 
continuous overnight monitoring (separate procedure) (94762) provided June 14, 2022. 
 
You asked the Plan to pay for the monitoring services. You say that you have submitted the medical records for 
the CPT code 94762. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 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 the monitoring services have been met. 
Additional records and information was needed from the provider to determine how the enrollee came to the 
servicing provider or whether the services were medically necessary. The records show that the Plan made 
multiple attempts to obtain needed medical records and additional information from the provider without 
success. Therefore, we decided that the Plan does not have to pay for noninvasive ear or pulse oximetry for 
oxygen saturation; by continuous overnight monitoring (separate procedure) (94762) provided June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on June 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that your physical therapist treated 
the enrollee in good faith and provided the medical care required. You request the services be approved for 
payment. The Plan denied your request. The Plan says the enrollee must receive care from a network 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 chiropractic manipulative treatment provided on 
June 1, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) submitted 
with modifier RW provided on June 22, 2022. 
 
You asked the Plan to pay for the emergency ambulance transportation submitted with modifier RW. You say 
that this claim is being denied for no valid reason. You also say that you would like this invalid denial 
corrected. The Plan denied your request. The Plan says the modifier is considered an invalid modifier for the 
service. 
 
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 A0429 is Ambulance service, basic life support, 
emergency transport (bls-emergency). 
 
We find that CPT code A0429 is not supported in the medical record. Specifically, since there is no evidence 
that modifier RW is a valid modifier to use for an ambulance service, A0429 is not supported. Based on this 
information, we decided that Medicare rules for coverage of the emergency ambulance transportation 
submitted with modifier RW have not been met. Therefore, we decided that the Plan does not have to pay for 
the emergency ambulance transportation (A0429) submitted with modifier RW provided on June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 that the enrollee is unable to tolerate intensive rehabilitation. The enrollee does not 
require frequent physiatry oversight and is at high risk of not returning to the community. 
 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95908 and 95886 provided on June 29, 
2021. 
 
You asked the Plan to pay for procedure codes 95908 and 95886. You say that the medical records support the 
billing of codes 95908 and 95886. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 95908 and 95886. 
 
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 95908 is Nerve conduction studies; 3-4 studies. The 
definition of code 95886 is Needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for 
primary procedure). 
 
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 procedure codes 95908 and 95886. Our reviewer says that the medical records do not support the billing of codes 95908 and 95886. Our reviewer found for code 95908, 
there was no indication in the records that a formal nerve conduction study has been performed in this episode 
of care. Rather, there was testing of the pedicle screws. This is a service that falls under the CPT code for EMG 
evaluation. There was no documentation that a formal NCS was done (with site stimulation and surface 
recording). In as much this code cannot be supported. For code 95886, the member did not have a NCS 
performed. As no NCS was done the use of CPT code 95886 would not have been the most appropriate code to 
be submitted to reflect the services provided for review. Therefore, this code is also not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95908 and 95886 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95908 and 95886 provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for wound care visits provided on April 19, 2022, and April 22, 2022. 
 
You asked the Plan to pay for wound care visits. You say that you are appealing all your denied claims because 
you did not have a primary care physician at the time you were admitted to the hospital. The Plan denied your 
request. The Plan says that an authorization was not obtained prior to services rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records showing the date of admission and 
discharge for the inpatient hospital stay. The Plan also did not submit records for the two visits in question. 
This means we are unable to determine the urgency of the additional visits and if there was adequate time to 
request prior authorization. Therefore, we decided that the Plan has to pay for wound care visits provided on 
April 19, 2022, and April 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eligard. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer. He has 
not tried and failed the Plan's required drug, Lupron. The records do not support that the required drug would 
be contraindicated or less effective; therefore, Eligard is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eligard.