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

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve these services. You say that you have a problem with your back which 
causes excruciating pain. The Plan denied your request. The Plan says that this service is considered 
experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that your condition does not meet 
criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional four physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional four PT visits. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says the services at issue are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an additional four PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills 
of a professional therapist are required to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. You should be able to transition to an independent home program at this point. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional four PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional four physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placements of implant body (D6010), 
prefabricated abutments (D6056) and implant-supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the implants, abutments, and crowns. You say that you are in pain and it is 
difficult to swallow. The Plan denied your request. The Plan says any dental services not listed in the Medicare 
Dental Benefit Limitations and Exclusions Guide, are not covered. 
 
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 
surgical placements of implant body (D6010), prefabricated abutments (D6056) and implant-supported 
porcelain/ceramic crowns (D6065).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a pneumatic compression device provided on July 11, 2020.
You asked the Plan to pay for this equipment. You say that this claim should be paid. The Plan denied your request. The Plan says your company was not appropriately licensed at the time of service. Maximus overturned the Plans denial stating no proof of the license status was included in the case file. The Plan requested a reopen and submitted documentation to show you were not licensed to provide this equipment on the date in question.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to an equipment vendor who is not an eligible, fully licensed provider. The documentation provided by the Plan and further research shows you were not licensed at the time of service. In addition, you were unable to provide the Plan with a copy of your license during the time of service. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided on July 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and trabeculoplasty by laser surgery provided 
on February 23, 2022, by an OON provider. 
 
You asked the Plan to pay for an office visit and trabeculoplasty by laser surgery. You say that you called the 
doctor's office and were told they do accept Medicare. You say that your optometrist referred you to this 
provider and made the appointment for you. The Plan denied your request. The Plan says the provider is out-of-
network and the Plan has in-network providers who can provide this service. 
 
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 and trabeculoplasty by laser surgery 
provided on February 23, 2022, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service October 1, 
2021. 
 
You asked the Plan to pay for procedure code 99601. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that it is imperative that the enrollee starts this 
medication soon. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step 
therapy criteria for the requested drug. 
 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 Feraheme. Our reviewer says that 
Feraheme is not reasonable and necessary. Our physician reviewer found the enrollee has not tried and failed 
the Plan's required drugs, Infed (Iron Dextran) and Venofer (Iron Sucrose). Our reviewer also found that the 
documentation does not support that Infed (Iron Dextran) and Venofer (Iron Sucrose) would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that the enrollee previously underwent Euflexxa 
injections with sustained response for only 4 months. The Plan denied your request. The Plan says the denial of 
authorization for this drug is correct, because there is no indication as to why Orthovisc cannot be used. 
 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 Monovisc. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Monovisc. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Orthovisc. The record does not show that 
this drug would be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Monovisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that you did not bill for the collection of this sample, so 
use of place of service (POS) code would not be appropriate. 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 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 provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded J1212, J1170, and J3490 
provided on November 17, 2021. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes J1212, J1170, and J3490 are not supported in the medical record. Specifically, these 
codes can only be used when a non-compound drug is used. There is more appropriate codes for to be billed for 
the services rendered. Based on this information, we decided that Medicare rules for coverage of the injection 
services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services 
coded J1212, J1170, and J3490 provided on November 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from October 
9, 2020, to December 8, 2020. 
 
You asked the Plan to pay for the SNF stay. You say that you believe you owe a copay but these charges seem 
excessive. The Plan denied your request. The Plan says the claim wasnt submitted until March of 2022 which 
is more than one calendar year from the date of service, which means it is not covered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the SNF stay was not filed until March 3, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for a skilled nursing facility (SNF) stay provided from October 9, 2020, to December 
8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift. 
 
You asked the Plan to pay for a stair lift. You say that there are seven stairs in your home and you are unable to 
navigate these without this device. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 27, 2022. 
 
You asked the Plan to pay for dental services. You say that the dentist in in-network. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested dental services are not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for dental services provided on January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 22551, 22845, and 22552 billed with the -82 modifier 
on date of service March 11, 2022. 
 
You asked the Plan to pay for codes 22551, 22845, and 22552 billed with the -82 modifier. You say that this 
was denied incorrectly because you appended the -82 modifier. The Plan denied your request. The Plan says 
the wrong modifier was billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Assistant-at-Surgery services, the physician 
modifiers are -80, -81, and -82.  The AS modifier should be used for physician assistants, nurse practitioners, 
and clinical nurse specialists. Records show that in this case, the Assistant-at-Surgery services were performed 
by a Physician Assistant, not a physician.  Non-physician Assistants-at-Surgery need to bill the AS modifier, 
not one of the physician-only modifiers. You billed these services with the -82 modifier incorrectly. Therefore, 
we decided that the Plan does not have to pay for codes 22551, 22845, and 22552 billed with the -82 modifier 
on date of service March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on May 5, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this is your first visit under the Plan, and this 
benefit has not been used. The Plan denied your request. The Plan says your benefit for periapical x-rays 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 periapical x-rays was exhausted on the same date of service May 5, 2022. Therefore, we 
decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on May 5, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a second duplex scan of extracranial arteries; complete bilateral study (93880-26-76) billed for date of service January 19, 2022.

You asked the Plan to pay for a second unit of 93880. You say that this service was billed appropriately, and the medical record supports this service as billed The Plan denied your request. The Plan says one unit of 93880 billed with modifier 26 has been paid for this date; the medical records provided do not support the billing of a second unit of 93880.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

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 a second unit of 93880 Our reviewer says that a second unit of 93880 is not supported for this date. Our physician reviewer found the provided documentation does not support an additional unit for this procedure. The reports do not include documentation for why a second procedure would have been performed. In this case, both the second procedure and the medical necessity of a second procedure cannot be verified.

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 second unit of 93880 have not been met. Therefore, we decided that the Plan does not have to pay for a second duplex scan of extracranial arteries; complete bilateral study (93880-26-76) billed for date of service January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) coded 
95957, the nerve conduction studies coded 95909, the neuromuscular junction testing coded 95937, and the 
needle electromyography coded 95885 provided on June 22, 2021. 
 
You asked the Plan to pay for the digital analysis of electroencephalogram (EEG), the nerve conduction 
studies, the neuromuscular junction testing, and the needle electromyography. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 95957, 95909, 95937, and 95885 are not supported in the medical record. Specifically, 
the technical report did not include documentation of a digital analysis of electroencephalogram (EEG) (for 
epileptic spike analysis); therefore coded 95957 cannot be verified. The technical report did not include 
documentation of nerve conduction studies; for 5-6 studies; therefore, code 95909 cannot be verified. The 
technical report did not include documentation of neuromuscular junction testing (repetitive stimulation, paired 
stimuli), per each nerve, by any 1 method; therefore, code 95937 cannot be verified. The technical report did 
not include documentation of a limited needle electromyography, per each extremity with related paraspinal 
areas when performed, done with nerve conduction, amplitude and latency/velocity study; (listed separately in 
addition to code for primary procedure); therefore, code 95885 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory 
evoked potential study, the digital analysis of electroencephalogram (EEG), the nerve conduction studies, the 
neuromuscular junction testing, and the needle electromyography have not been met. Therefore, we decided 
that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) coded 95957, the 
nerve conduction studies coded 95909, the neuromuscular junction testing coded 95937, and the needle 
electromyography coded 95885 provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine exam provided on February 15, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the routine exam. You say that your claim was denied, but your wife's claim for 
the same doctor was approved. The Plan denied your request. The Plan says these services were rendered by an 
OON provider. The Plan also says that you did not contact the Plan prior to this date of service to verify 
benefits and provider eligibility. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by an in-network optical provider. 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. These services were rendered by an OON provider. Based on this 
information, we decided that the Plan's rules for coverage of the routine exam have not been met. Therefore, we 
decided that the Plan does not have to pay for the routine exam provided on February 15, 2022 by an out-of-
network (OON) provider.