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

 
We decided that the Plan does not have to pay for the diagnostic laboratory services provided on June 21, 2021. 
 
You asked the Plan to pay for the diagnostic laboratory services. You say that you would like this claim fully 
paid. The Plan denied your request. The Plan says the Plan is the secondary insurer, and the primary insurer 
must pay this claim first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has listed the 
primary insurer in their letter and directed you to bill this plan first. As the secondary insurer, the Plan cannot 
be held responsible for the diagnostic laboratory services until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for the diagnostic laboratory services 
provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services 
(87798) provided on January 25, 2022. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says more 
information was needed to document the medical necessity of the services at issue. 
 
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 infectious agent detection by 
nucleic acid services (87798) provided on January 25, 2022, have been met. In this case, the Plan needed more 
information to support the medical necessity of the billing of code 87798 exceeding the MUE. No medical 
information detailing the necessity of the services was returned. Therefore, we decided that the Plan does not 
have to pay for the infectious agent detection by nucleic acid services (87798) provided on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology provided on April 7, 2021, and billed with
codes 88127 and 88173.
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 Medicare billing criteria were not met. Maximus partially overturned the Plans denial,
stating there was no confirmation in the case file regarding the outcome of code 88173. The Plan requested a
reopen and provided documentation to show code 88173 was previously processed and paid.
The Plan is correct in this case regarding code 88172. The Plan must follow Medicare rules. Medicare rules say
that providers must report services correctly. Providers must report services with the appropriate codes. The
Medicare billing and coding rules indicate an edit exists between codes 88172 and 88104. Code 88172 has not
been billed with an appropriate modifier to bypass this edit and is not separately payable. Therefore, we
decided that the Plan does not have to pay for code 88172.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve orthovisc for the enrollee. 
 
You asked the Plan to pre-approve orthovisc. You say that this is medically necessary in order to regain 
maximum functionality. The Plan denied your request. The Plan says that that the enrollee does not have 
documented osteoarthritis of the knee that is causing symptoms. 
 
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 orthovisc. Our reviewer says that 
orthovisc is medically reasonable and necessary. A medical visit note dated June 24, 2022, indicates the patient 
"has tried quad strengthening exercise, activity modifications, relative rest, cortisone injections, anti-
inflammatories." Radiologic imaging of the right knee on December 11, 2020, showed "mild medial 
compartment joint space narrowing." A magnetic resonance scan on July 7, 2021, showed degenerative 
changes also. The June 24, 2022, visit note also states the prior viscosupplementation injections resulted in 
"relief of symptoms, increased mobility and activity, with less pain, decreased need for pain control." Our 
physician reviewer found that the enrollee's condition meets criteria for coverage of orthovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of orthovisc have been met. Therefore, we decided that the Plan has to pre-approve 
orthovisc for the enrollee.  
 
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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that these stockings are medically 
necessary for your condition. The Plan denied your request. The Plan says these are not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional extractions (D7210), provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
services. 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 will be exhausted with 8 of the approved extractions. The additional 8 extractions have been correct denied. Therefore, we decided that the Plan does not have to pre-
approve 8 extractions (D7210), provided by a participating provider.
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 it is in the best interest of the patient to be considered 
a candidate for a specialized rehabilitation program to address his need post stroke. The Plan denied your 
request. The Plan says per the Medicare Benefit Policy Manual, the criteria is not met for IRF as the member is 
not able to tolerate an intensive rehabilitation therapy program of at least three hours per day at least five days 
per week. 
 
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 enrollee cannot actively participate in or benefit from an intensive rehabilitation 
program. Our physician review also found that the enrollee does not require frequent physiatry oversight as he 
does not have muscle spasms, or autonomic instability. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and prefabricated post and core for tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services because you are in 
pain. The Plan denied your request. The Plan says your benefit for the crown has already been exhausted. The 
Plan also says that the prefabricated post and core for tooth #30 is not a covered service. 
 
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, you also have a maximum benefit of 
one crown per calendar year. The Plan paid for a crown for tooth #11 provided on April 18, 2022, which 
exhausted your benefit. In addition, the prefabricated post and core is not a covered service under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve to pre-approve a crown and prefabricated 
post and core for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on January 13, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you saw your primary 
dentist on January 4, 2022, and they referred you to an endodontist for a root canal. You also say that you 
would like the consult to be covered. 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 Plan's 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 January 4, 2022.  
 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuvasive Osteocel Allograft for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the use of this product during spinal surgery is better than standard allograft products (material used during surgery to help new bone grow).

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that nuvasive osteocell allograft is experimental as not much research has been done on the porduct in humans and it and has not been shown to be better than simple conventional crushed allograft chips. It is not medically 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Nuvasive Osteocel Allograft for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup provided on January 27, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that the tooth under the old crown was 
deteriorating and the gaps in my gum line were worsening. You say that you were told by the dentist this had to 
be done. The Plan denied your request. The Plan says restorative dental benefits 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, restorative dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
and core buildup provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unspecified periodontal procedures (D4999 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that without approved laser the necessary 
procedure cannot be performed. The Plan denied your request. The Plan says the requested services are not 
listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pre-approve the unspecified periodontal procedures 
(D4999 x 2).
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 you are appealing based on the medical necessity for 
IRF admission. The Plan denied your request. The Plan says the criteria for IRF admission was not meet. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as a skilled 
nursing facility (SNF), home health, or long-term care. 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. 
 
At the current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. IRF admission is not 
medically necessary based lack of medical complexity and acute rehabilitation nursing needs. 
 
While the enrollee may benefit from continued physical therapy and occupational therapy, the enrollee's 
rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in an 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ProText. 
 
You asked the Plan to pre-approve ProText. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the clinical value and effectiveness of ProText in the setting of 
osteoarthritis and associated knee pain has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 ProText. Our reviewer says that 
ProText is not medically reasonable and necessary. ProText is not Food and Drug Administration-approved for 
your diagnosis. Use of ProText for osteoarthritis of the knee is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Use of ProText for 
osteoarthritis of the knee is not indicated, supported or recommended in any of the compendia. Our physician 
reviewer found that your condition does not meet criteria for coverage of ProText. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ProText have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ProText.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on May 29, 2020.
You asked the Plan to pay for the coronavirus testing. You say that the medically necessary service was provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the member does not appear to meet Medicare criteria for an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 there is no evidence in the clinical documentation that patient requires intense 
therapy thus IRF criteria have not been 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional chiropractic visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 records are insufficient to support 
the coverage of additional chiropractic visits beyond the three approved by the Plan. Medicare does not cover 
maintenance therapy. 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional chiropractic visits.