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

 
We decided that the Plan does not have to pre-approve Zarxio. 
 
You asked the Plan to pre-approve Zarxio. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zarxio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of breast cancer and is receiving Ibrance (palbociclib) and Faslodex (fulvestrant) chemotherapy 
which is not considered myelosuppressive and is low risk for febrile neutropenia. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot 
be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zarxio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left greater trochanter bursa injection (20610) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a left greater trochanter bursa injection to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a left greater trochanter bursa injection (20610) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), the cleaning 
(D1110), the bitewing x-rays (D0274), the intraoral periapical x-ray (D0220), and the additional periapical x-
rays (D0230) provided by an out-of-network provider on June 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you can have two procedures per years, 
and the services should be covered. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodic oral evaluation (D0120), the 
cleaning (D1110), the bitewing x-rays (D0274), the intraoral periapical x-ray (D0220), and the additional 
periapical x-rays (D0230) provided by an out-of-network provider on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that you could only have one 
x-ray per year. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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 the requested item or service was exhausted on date of service March 31, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) 
provided on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87324, 87801) provided on June 21, 
2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150, 87324, 87801) provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and an 
occlusal guard  hard appliance, full arch (D9944) provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you knew this service was not covered under 
your insurance. You also say that the financial representative at the dental office stated this should not have 
been submitted to insurance and you were informed of that at the time of service. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted or is not covered under 
the benefit package. 
 
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 the limited oral evaluation - problem focused (D0140), was exhausted on dates of 
service March 10, 2022, and September 12, 2022. Therefore, we decided that the Plan does not have to pay for 
a limited oral evaluation - problem focused (D0140), and an occlusal guard  hard appliance, full arch (D9944) 
provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic (D6740), and pontic - 
porcelain/ceramic (D6245) provided on July 11, 2022. 
 
You asked the Plan to pay for the retainer crown - porcelain/ceramic (D6740), and pontic - porcelain/ceramic 
(D6245). You say that you had a seizure at work and broke your bridge and lost teeth causing you to need a 
new bridge. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown - porcelain/ceramic (D6740), and pontic - porcelain/ceramic (D6245) provided on July 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service March 18, 
2022. You asked the Plan to pay for the billed services. You say that the documentation supports the billed codes. 
The Plan denied your request. The Plan says the code cannot be verified. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the medical records do not indicate the amount of time spent with the enrollee. 
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 procedure code 99291 billed for date of 
service March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided on June 8, 2022, to 
August 8, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you cannot afford to pay the 
coinsurance for dialysis. 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 20% 
coinsurance for Medicare-covered renal dialysis. 
 
  You have been asked to pay $1,429.35 for dialysis procedure.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
June 8, 2022, to 
June 21, 2022 
Dialysis procedure $1,381.80 20% $276.36 
June 22, 2022, to 
June 29, 2022 
Dialysis procedure $1,542.55 20% $308.50 
July 1, 2022, to 
July 6, 2022 
Dialysis procedure $1,231.32 20% $246.28 
July 8, 2022, to 
July 21, 2022 
Dialysis procedure $1,379.56 20% $275.94 
July 5, 2022, to 
July 29, 2022 
Dialysis procedure $691.41 20% $138.27 
August 1, 2022, to 
August 8, 2022 
Dialysis procedure $920 20% $184 
TOTAL:    $1,429.35 
 
Dialysis procedure falls within the Services to treat kidney disease 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 coinsurance for dialysis provided on June 8, 2022, to August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden 
variant.. You say that this testing is medically necessary due to family history. The Plan denied your request. 
The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care to be associated with an 
elective carotid angioplasty. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needs inpatient care. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than two midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that that you are to undergo a procedure that is not on the inpatient only list. There is 
no documentation of a need for early hospitalization pre-procedure. You should present for the procedure as an 
outpatient. Should complications arise during or after the procedure that require a prolonged hospitalization, 
you can be converted to inpatient status at that time under the two-midnight rule. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care to be associated with an elective carotid 
angioplasty.
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 you can only walk a small distance before becoming 
tired. You say you should have had inpatient care after back surgery, but did not, which delayed your healing 
progress. The Plan denied your request. The Plan says you do 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to be admitted to the IRF to get 
stronger. The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 clinical documentation shows that you have complex functional impairments. 
However, no active medical comorbidities are specified. The reviewer also found your anemia is now stable. Thus, the complexity of your documented nursing, medical, and rehabilitation needs would not be expected to 
require an IRF stay with an interdisciplinary approach to rehabilitation care. IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bystolic capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that this drug is needed. The Plan denied 
your request. The Plan says this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Bystolic capsules.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 5, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that there is no documentation of pharmacogenomic testing on the date of service appropriately billed with Place of Service (POS) 81. The provider performed a pharmacogenomic panel. The laboratory billed multiple individual CPT codes with the same date of service. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Providers/suppliers must not unbundle the services described by a specific code. If one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. The sample (buccal swab) was collected on April 5, 2021, and not received by the laboratory until April 15, 2022, indicating that the specimen was not collected directly by the laboratory.
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 code. In this case, this claim could not be paid due to issues with the codes billed and the POS code reported. 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 April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIg) for Privigen. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have a condition indicated for coverage. 
 
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 the requested services. Our physician 
reviewer found that the enrollee has hypogammaglobulinemia with an Immunoglobulin G (IgG) of 584 mg/dl. 
The record does not indicate well-documented severe polysaccharide non-responsiveness and evidence of 
recurrent infections with a proven requirement for antibiotic therapy. The record does not document an 
enumerated condition for which coverage is available under the coverage criteria. The elements of the coverage 
criteria are not satisfied. Therefore, the requested service is not recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intravenous immune globulin (IVIg) for Privigen.