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

 
We decided that the Plan does not have to pay for the presumptive drug testing rendered on November 18, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that it is not reasonable and necessary for a physician to 
perform presumptive POCT and order presumptive IA testing from a reference laboratory. 
 
We looked at the file and Medicare rules. The file shows that the presumptive testing was ordered by a 
physician from a reference laboratory. 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 pay for the 
presumptive drug testing rendered on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin based composites (D2332) provided on December 
10, 2021. 
 
You asked the Plan to pay for the resin based composites. You say that you would like reconsideration because 
the provider used resin fillings as opposed to silver which are less expensive. The Plan denied your request. 
The Plan says this is not a covered benefit under your dental plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin 
based composites (D2332) provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 22, 2021.
You asked the Plan to pay for this testing. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan presented documentation to
show that this claim denied because the provider billed this service inappropriately. The Plan submitted
specific documentation of only 18 drug classes counted from the laboratory results received. Code G0483 is
only used when 22 or more classes were tested. The Plan states there is another more appropriate code for the
services provided and the provider billed the wrong code.
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, the Plan has
provided lab results to show less than 22 classes were tested, meaning this claim was not coded appropriately.
Medicare uses another code for testing resulting in less than 22 classes of drugs. Therefore, we decided that the
Plan does not have to pay for drug testing provided to the enrollee on May 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 Superion device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is experimental and more research is needed to show its safety and 
efficacy. 
 
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 Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, below knee, alignable 
system (L5910). 
 
You asked the Plan to pre-approve the below knee, alignable system. You say that the documentation enclosed 
supports that code L5910 is reasonable, medically necessary and is beneficial to improving the enrollee's overall 
success to increase mobility managing her health. The Plan denied your request. The Plan says the preparatory 
prosthesis is a non-alignable system, therefore the requested prosthetic component does not meet the medical 
necessity criteria. 
 
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 below knee, alignable system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested items exceed the enrollee's medical need as the enrollee's 
current approved preparatory prosthesis is non-alignable and at this time the alignable system is not appropriate 
for the enrollee's functional level. 
 
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 below knee, alignable system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the addition, endoskeletal system, below knee, alignable system (L5910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 extractions provided on December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for these services. The 
Plan denied your request. The Plan says the claim denied correctly. 
 
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 extraction are not among those 
covered under this benefit. The record shows that you were not enrolled in the optional supplemental dental 
benefit on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the 3 
extractions provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 1, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that this service was necessary. The Plan denied your 
request. The Plan says this eye refraction was provided as part of a medical eye exam and was not performed 
by a provider in the specified vision vendor network as required by the contract. 
 
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 only when they are performed as part of a routine (non-medical) eye 
exam and received from a provider within the Plans specified routine vision vendor network. 
 
We looked at the file and the Plan's rules. This service was provided as part of a medical (non-routine) eye 
exam by a provider who does not participate in the Plans routine vision vendor network. Based on this 
information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, 
we decided that the Plan does not have to pay for the eye refraction (92015) provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests (K0195). 
 
You asked the Plan to pre-approve elevating leg rests. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the records do not support that the 
requested elevating leg rests are 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 elevating leg rests. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records do not document the enrollee has a musculoskeletal condition or 
the presence of a cast or brace which prevents 90-degree flexion at the knee or has significant edema of the 
lower extremities that requires an elevating leg rest, or the enrollee meets the criteria for and has a reclining 
back on the wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elevating leg rests have not been met. Therefore, we decided that the Plan does 
not have to pre-approve elevating leg rests (K0195).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that the enrollee has failed other medications. The Plan 
denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 
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 Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. While you may benefit from physical therapy, and occupational therapy, your rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the drug testing rendered on September 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be somewhat unstable still and requires additional short-term 
acute care services that can be safely administered at the current facility until more stable for a lower level of 
care. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility. Transfer to LTACH is not medically necessary as the enrollee is not stable and as it would 
not be clinically advantageous. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of 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.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of 
coronary artery disease, diabetes, and anemia and is living at home with weakness and several recent falls. The 
enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transport brackets. 
 
You asked the Plan to pre-approve transport brackets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says transport brackets are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve transport brackets.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
 
 
 
 
 We looked at the file and Medicare rules. Per Medicare rules, the requested urine validity testing is not 
separately payable. 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 the lab services provided on October 
18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device (22869). 
 
You asked the Plan to pre-approve the vertiflex device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
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. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental and requires more research on its safety and efficacy. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the vertiflex device (22869).
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 you will benefit significantly from IRF care. The 
Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. Your 
ongoing skilled therapy and nursing needs can be provided at a lower level of 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 that you are medically stable and do not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehabilitation nursing needs identified 
or documented in the record. At your current functional level, you do not need IRF level of therapies, and your 
rehabilitation needs can be met in-home with physical therapy. An IRF admission is not medically necessary 
based on medical stability and lack of medical complexity, and lack of rehabilitation nursing needs and high 
functional level. The documentation does not support the necessity for admission to an IRF. While you may 
benefit from physical therapy and occupational therapy, your rehabilitation can be safely provided at a lower 
intensity and alternate setting such as in-home with physical therapy. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit for the enrollee. 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollees most recent Hgb level is greater than 11 g/dL and the dose has not 
been reduced. 
 
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 Retacrit. Our reviewer says that 
Retacrit is not medically reasonable and necessary. Retacrit is not FDA-approved for the enrollees diagnosis 
with a hemoglobin of 11.9. The use of Retacrit is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of Retacrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit for the enrollee.