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

 
We decided that the Plan does not have to pre-approve computed tomography (CT) soft tissue neck (70491). 
 
You asked the Plan to pre-approve computed tomography (CT) soft tissue neck (70491). The Plan denied your 
request. The Plan says the results of a prior ultrasound (picture study using sound waves) must have failed to 
find the source of your problem, the request for a computed tomography (CT) soft tissue neck (70491) cannot 
be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve computed tomography (CT) soft tissue 
neck (70491). Our reviewer says that the service is not medically necessary. Our physician reviewer found 
based on the results of the history, physical exam, and imaging, swelling was not concerning and would not 
warrant advanced imaging follow up at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computed tomography (CT) soft tissue neck (70491) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) soft tissue neck 
(70491).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services (99226) provided on September 2, 
2022. 
 
You asked the Plan to pay for the observation services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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. 
 
In this case, the CPT Code Manual definition of code 99226 is Subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed 
interval history; a detailed examination; and Medical decision making of high complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the observation services. Our reviewer says that the code 
billed is not supported in the records. Our reviewer found records in this case do not document an extensive 
amount and complexity of data reviewed and high risk of complication. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the observation services have not been met. Therefore, we decided that the Plan 
does not have to pay for observation services (99226) provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95165 rendered on October 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 95165 is "Professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the record does not support 30 
units of CPT code 95165. According to Medicare guidelines, the dose is defined as the amount of antigen(s) administered. According to the records, 22 antigens were included. 
 
We looked at this coder'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 pay for procedure code 95165 rendered on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
procedure is considered experimental for knee pain. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic right knee pain. This procedure is the subject of ongoing clinical 
trials and is considered experimental/ investigational.  Therefore, the request is deemed not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination and scanning computerized ophthalmic 
diagnostic imaging provided on October 24, 2022. 
 
You asked the Plan to pay for an eye examination and scanning computerized ophthalmic diagnostic imaging. 
You say that you called the provider and the Plan and confirmed the provider was in-network. The Plan denied 
your request. The Plan says the provider is not a contracted provider with your plan and no prior authorization 
was requested or approved. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved 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 pay for an eye examination and scanning 
computerized ophthalmic diagnostic imaging. Our physician reviewer found the enrollee could have foreseen 
the services prior to leaving their service area, as their ocular conditions were chronic and stable.  There was no new acute vision threatening condition or eye pain noted on the evaluation on October 24, 2022. The records 
support that the evaluation was appropriate and medically necessary. However, the evaluation could have been 
performed in the enrollees service area or delayed until October 31, 2022. It would have been medically 
reasonable to delay the services until October 31, 2022, when the enrollee disenrolled from the Plan.  
The enrollee's ocular conditions of non-exudative age-related macular degeneration, dry eyes, and primary 
open angle glaucoma were all chronic conditions, and the ophthalmology examination did not document any 
acute issues that required urgent evaluation on the date of service.  
 
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 eye examination and scanning computerized ophthalmic diagnostic imaging 
have not been met. Therefore, we decided that the Plan does not have to pay for an eye examination and 
scanning computerized ophthalmic diagnostic imaging provided on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If the enrollee has chronic carbon dioxide (CO2) retention, may benefit from bilevel positive airway 
pressure (BiPAP) during sleep as an outpatient. This has not been tried and shown to fail. The enrollee does not 
have a diagnosis for which Medicare covers a home ventilator. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you have multiple chronic 
illnesses, and are at high risk for being in the hospital. You also say that this benefit was the reason you 
changed to this plan. The Plan denied your request. The Plan says based on the information submitted there is 
no documentation that you meet all 3 criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination. 
 
 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 SSBCI benefits. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found you have a documented and active 
diagnosis for one or more of the qualifying comorbid and medically complex conditions. Our reviewer also 
found that there is no documentation provided indicating that you require intensive care management or are at 
high risk for hospitalization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do 
not have an eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not 
have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve MPI. 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 follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary under certain circumstances. 
 
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 MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel that your primary care physician 
(PCP) did not fill out the form according to your health conditions. The Plan denied your request. The Plan 
says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Calreticulin Exon 9 Mutation Detection, Jak2 Exon 12 Mutation 
Analysis and MPL Mutation Analysis (81403, 81219, 81402). 
 
You asked the Plan to pre-approve genetic testing. You say that there is no medical necessity needed to test for 
BCR-ABL. The Plan denied your request. The Plan says that the requested genetic testing does not meet the 
requirements for approval. 
 
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 pre-approve genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has laboratory work suspicious for polycythemia vera (PV) and not for CML. A 
BCR-Abl is not medically necessary for the work-up of this enrollee. Per the NCCN Guidelines and established 
algorithms for the work-up of PV is to test for Calreticulin Exon 9 Mutation Detection, Jak2 Exon 12 Mutation 
Analysis and MPL Mutation Analysis. This would be a standard of care in an enrollee with a normal EPO level 
such as this one. The service is reasonable and 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 genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve Calreticulin Exon 9 Mutation Detection, Jak2 Exon 12 Mutation Analysis and MPL Mutation Analysis 
(81403, 81219, 81402).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Grafix Core and GrafixPL Core, per sq cm (Q4132), 
Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm (Q4133), application of skin substitute 
graft, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (15275), and 
application of skin substitute graft, total wound surface area up to 100 sq cm; each additional 25 sq cm wound 
surface area, or part thereof (15276). 
 
You asked the Plan to pre-approve Grafix Core and GrafixPL Core, per sq cm, GrafixPL PRIME, Stravix and 
StravixPL, per sq cm and application of skin substitute graft. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Grafix Core and GrafixPL Core, per sq 
cm, GrafixPL PRIME, Stravix and StravixPL, per sq cm and application of skin substitute graft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollees diabetes is poorly controlled, indicating a failure to provide standard 
therapy. Despite the poorly controlled diabetes, the enrollees wounds have actually been improving, meaning 
that a change in the current wound care is not warranted. The requested skin grafts are not medically necessary 
or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Grafix Core and GrafixPL Core, per sq cm, GrafixPL PRIME, Stravix and 
StravixPL, per sq cm and application of skin substitute graft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Grafix Core and GrafixPL Core, per sq cm (Q4132), Grafix PRIME, 
GrafixPL PRIME, Stravix and StravixPL, per sq cm (Q4133), application of skin substitute graft, total wound 
surface area up to 100 sq cm; first 25 sq cm or less wound surface area (15275), and application of skin 
substitute graft, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part 
thereof (15276).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for a computed tomography scan provided on January 31, 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 provided additional information regarding the claim. The Plan showed 70450 was billed under PMG related claim (Claim A) by a capitated provider. If a provider is capitated for a particular service, this indicates the provider has been paid in advance for this service under capitation and has taken on the financial risk of payment for the service. The Plan states outreach was made to request and obtain a copy of the claim and explanation of payment. It was also determined the claim denied did not include the modifiers required for payment as a separate service.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case this claim could not be paid as billed due to the capitation agreement and the omission of the required modifiers. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography scan provided to the enrollee on January 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
You asked the Plan to pre-approve Monoferric. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Monoferric. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that Infed (iron dextran) 
and Venofer (iron sucrose) would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine 
showing the lumbar and cervical regions. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical records do not show that the enrollee has completed 6 weeks of 
provider treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
cervical and lumbar radiculopathy. The records provided do not indicate that the enrollee has any red flag 
symptoms or abnormal neurological findings. The records provided do not indicate that the enrollee has failed a 
course of conservative treatment. The requested service is not medically necessary and reasonable for the 
diagnosis and treatment for the enrollee's clinical condition at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the spine showing the lumbar and cervical regions.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Farxiga. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is needed by the enrollee. 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 use of Farxiga.  
 
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.