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

 
We decided that the Plan does not have to pre-approve Hyalgan injections. 
 You asked the Plan to pre-approve the Hyalgan injections. You say that it is felt that the requested treatment is 
needed. The Plan denied your request. The Plan says there is no reason noted that a preferred agent cannot be 
used for this treatment. 
 
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 Hyalgan injections. Our reviewer 
says that the requested drug is not medically necessary based on step therapy criteria. Our physician reviewer 
found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Hyalgan injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyalgan injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0364). 
 
You asked the Plan to pre-approve a cone beam CT capture and interpretation. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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 pre-approve a 
cone beam computed tomography (CT) capture and interpretation (D0364).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 14, 2022, to 
April 18, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim should be paid. The Plan denied your request. The Plan says the Plan is upholding the Plan's decision to 
remove secondary code N17.0 (Acute Kidney Failure with Tubular Necrosis [ATN]) and maintain a change 
from DRG 919 to DRG 921. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N17.0 (Acute Kidney Failure with Tubular Necrosis 
[ATN]). 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 inpatient hospital services at the 
DRG originally billed. Our physician reviewer found the documentation does not consistently and completely 
support the assigned secondary diagnosis code. The decision to remove the secondary diagnosis code and 
adjust the DRG is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 14, 2022, to April 18, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for code 76641 billed for date of service August 16, 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. The Plan requested a reopen and stated Maximus applied the wrong billing criteria. The Plan notes the Maximus review states that "we find that CPT code 76641 was billed with 1 unit of service with modifier RT on one claim line, and 1 unit of service and modifier LT on a second claim line. We also find that code 76641 has an MUE of 2, not 1."
However, the Plan states per the Medicare MUE Practitioner Services sheet Effective July 1, 2022, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2 indication this is a date of service edit. The MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022, update. As the date of service in question is August 16, 2022, the new MUE value of 1 would apply. The Plan states the archived version of the MUE sheets can be found at the following web address: https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/nccimedicare/medicare-ncci-mue-archive.
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, the claim could not be paid as billed due to an error with the MUE value on the code billed, 76641. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for to pay for procedure code 76641 billed for date of service August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845). 
 
You asked the Plan to pre-approve a knee-shin system. You say that you feel these are medically necessary for 
the enrollee's prosthesis. The Plan denied your request. The Plan says the requested knee shin system cannot be 
used for this device and is unbundled. Although the vendor uses code L5845 for this knee, neither the 
manufacturer nor the vendor has the authority to assign this code to the requested knee. 
 
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 a knee-shin system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, additional features or components to a prosthesis may be 
necessary depending on the enrollee's potential functional abilities. Potential functional ability is based on the 
reasonable expectations of the prosthetist, and treating practitioner, considering multiple factors. These factors 
include the enrollee's past history, current condition including the status of the residual limb and the nature of 
the other medical problems and the enrollee's desire to ambulate. In this case, the health plan has authorized an 
appropriate lower extremity prosthesis that matches the enrollee's functional level. There is no documentation 
available for review that supports the requested item as the authorized prosthesis has an endoskeletal, knee shin 
system, single axis, friction swing and stance phase control. The requested item appears to be a duplicate and is 
not 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 knee-shin system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve aide services. You say that the requested aide services are medically 
necessary. The Plan denied your request. The Plan says that the requested custodial services are not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of aide services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home health 
aide services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Keytruda 100MG/4ML solution (J9271). 
 
You asked the Plan to pre-approve the medication. You say that Keytruda is approved for treatment of the 
enrollee's cancer. The Plan denied your request. The Plan says the medication is not medically necessary. 
 
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 the medication. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollees diagnosis. FDA approval is for 
first-line, single-agent treatment of nonsmall cell lung cancer (NSCLC) in patients with stage III NSCLC 
(who are not candidates for surgical resection or definitive chemoradiation) or in patients with metastatic NSCLC, and with tumors with PD-L1 expression (tumor proportion score [TPS] greater than or equal to 1%), 
as determined by an approved test, and with no epidermal growth factor receptor (EGFR) or anaplastic 
lymphoma kinase (ALK) genomic tumor aberrations. 
 
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 the Keytruda 100MG/4ML solution (J9271).
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 is not able to return home and not able to 
complete self-care without assistance requiring therapy to regain full mobility. The Plan denied your request. 
The Plan says the enrollee does not show that you need an intensive team, services needed can be provided 
safely in other settings, a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the colonoscopy with biopsy (45380) and the colonoscopy with lesion removal (45385) provided on May 20, 2022.
You asked the Plan to waive the coinsurance for the colonoscopy with biopsy and the colonoscopy with lesion removal. You say that the provider should have advised there would be a coinsurance before this service was rendered. 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 20% coinsurance for a diagnostic colonoscopy.
You have been asked to pay a 20% coinsurance for the colonoscopy with biopsy and the colonoscopy with lesion removal. This item/service falls within the diagnostic colonoscopy 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 the colonoscopy with biopsy (45380) and the colonoscopy with lesion removal (45385) provided on May 20, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for code 76641 billed for date of service September 09, 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. The
Plan requested a reopen and noted that per the Medicare MUE Practitioner Services sheet Effective July 1,
20222, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2 indication this is a
date of service edit. Please note that the MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022,
update. As the date of service in question is September 09, 2022, the new MUE value of 1 would apply.
The archived MUE sheets can be found at the following web address: https://www.cms.gov/medicaremedicaid-
coordination/national-correct-coding-initiative-ncci/nccimedicare/medicare-ncci-mue-archive
Per the above Medicare guidelines, the Plan has correctly denied the claim for payment.
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 as billed due to the MUE value for code 76641. Therefore, we decided that the Plan does not
have to pay for to pay for procedure code 76641 billed for date of service September 09, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan or derivative (J7318).
You asked the Plan to pre-approve Hyaluronan or derivative. You say that this is medically necessary. The Plan denied your request. The Plan says that Hyaluronan injections are not medically necessary given your current conditions.
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. Our Medical director looked at the case file and the reopen request. At issue is coverage for Hyaluronan or derivative. Our Medical Director states that the case file does not contain documentation of trial and failure of two preferred medications. The documentation does not support that two preferred medications, Supartz FX, Hyalgan, Euflexa, and/or Synvisc One, would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that your condition does not meet step therapy criteria for Hyaluronan or derivative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyaluronan or derivative have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative (J7318).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from July 9, 2021, to
July 16, 2021, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the
services at issue have been billed correctly. The Plan denied your request. The Plan says that rules for payment
have not been met.
Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with principal
diagnosis code, A41.9, defined as Sepsis, unspecified. Our Medical Director states that a constellation of
clinical, laboratory, radiologic, physiologic, and microbiologic data is typically required for the diagnosis of
sepsis. The available clinical documentation is insufficient to support a diagnosis of Sepsis. Our Medical
Director found the enrollee's condition did not meet Medicare criteria for the inpatient hospital services
provided from July 9, 2021, to July 16, 2021, at the DRG originally billed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided from July 9, 2021, to July 16, 2021, at the Diagnosis Related Group
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the Vertiflex procedure is 
minimally invasive and is clinically proven for long term relief. You say that this is an approved procedure, and 
you need this to be able to function. The Plan denied your request. The Plan says there are not enough studies 
on Vertiflex Superion to show it is safe and effective. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that current evidence based medical guidelines do not fully support the 
spinal decompression device procedure over the standard lumbar laminectomy. There is a lack of large volume 
studies to support the use of this device for your medical 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 the Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery. 
 
You asked the Plan to pre-approve proton treatment delivery. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are 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 proton treatment delivery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has resectable left lower lobe nonsmall cell lung cancer. For the 
treatment of stage I non-small cell lung cancer, proton therapy is not considered a standard of care. The NCCN 
Guidelines do not support proton beam therapy for this indication (1st line) over standard stereotactic body 
radiation therapy (SBRT). Therefore, the enrollee does not meet criteria for the requested services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for GenVisc injections provided on January 21, 2022. 
 
You asked the Plan to pay for GenVisc injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that this service is experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for GenVisc injections. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found viscosupplementation for the enrollee's condition is considered the standard of care. This service 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 GenVisc injections have been met. Therefore, we decided that the Plan has to 
pay for GenVisc injections provided on January 21, 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.