Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio therapy system (K1018). 
 
You asked the Plan to pre-approve a Cala Trio therapy system (K1018). You say that the requested Cala Trio 
therapy system is medically necessary. The Plan denied your request. The Plan says the requested Cala Trio 
therapy system is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Cala Trio therapy system (K1018). 
Our reviewer says that the requested Cala Trio therapy system is not medically necessary. Our physician 
reviewer found there is insufficient evidence in the literature that this device is effective for the enrollee's 
tremor. The requested Cala Trio therapy system is not the standard of care for this enrollee's tremor according 
to current guidelines.   
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 Cala Trio therapy system (K1018) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Cala Trio therapy system (K1018).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant device. 
 
You asked the Plan to pre-approve a cochlear implant device. You say that a cochlear implant device is 
medically necessary. The Plan denied your request. The Plan says a cochlear implant device is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a cochlear implant device is covered when the criteria 
listed in the Medicare rules section of this decision are met. 
 
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 cochlear implant device. Our reviewer 
says that the requested cochlear implant device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
cochlear implant device at issue in this case meets all Medicare criteria for medically reasonable and necessary 
and safe and effective for the patient. The provided records include computed tomography scanning showing 
opacification of the bilateral middle ear cavities concerning for chronic otitis media. The provided records in 
this case do not document "freedom from middle ear infection" as is required by the National Coverage 
Determination (NCD: 50.3) Cochlear Implantation for coverage.  
 
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 cochlear implant device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cochlear implant device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 6, 2023. 
 
You asked the Plan to pay for OIVIT 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 OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0117U) provided on June 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. 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, for 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 (0117U) provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy rendered on April 20, 
2023. 
 
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 ultraviolet cabinets are covered for selected patients 
with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. The file shows that the enrollee did not have a diagnosis of 
intractable psoriasis. 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 ultraviolet (UV) light 
therapy rendered on April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 8, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on August 8, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiologic examination (x-ray) of the ankle (73610) provided on 
July 21, 2023. 
 
You asked the Plan to pay for the x-ray. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says that code 73610 is included in the emergency department evaluation 
and management (E/M) (99213) payment. This code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that when carriers receive only one claim for an 
interpretation, they must presume that the one service billed was a service to the individual beneficiary rather 
than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary 
test. 
 
We looked at the file and Medicare rules. In this case, we can see that the progress note includes a complete 
written report of the x-ray findings signed by the provider, and there is no evidence that payment was made to 
any other provider for the interpretation of this x-ray. Based on this information, we decided that Medicare 
rules for coverage of the x-ray have been met. Therefore, we decided that the Plan has to pay for the radiologic 
examination (x-ray) of the ankle (73610) provided on July 21, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 8, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58710, this type of testing must be billed with a single unit of service of a single code 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on August 8, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 14, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service July 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorper. 
 
You asked the Plan to pre-approve Prochlorper. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the 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 Prochlorper.  Benefits for Prochlorper 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 7, 2023, to July 
7, 2023. 
 
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. The rules say that all home health prospective payment system (HH PPS) 
claims must be submitted with type of bill (TOB) 0329. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB 
code. 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 home health services rendered from June 
7, 2023, to July 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation billed for date of service
October 17, 2022.

You asked the Plan to pay for the ambulance transportation. You say that the records show transportation was
medically necessary. The Plan denied your request. The Plan says that the services are not payable as billed.
Maximus overturned the Plan's denial because of a lack of information. The Plan requested a reopening and
stated that the claim is not payable. The Plan is correct in this case. Medicare rules state that claim lines
submitted with the GY modifier are non-covered and will be denied. The claim submitted to the Plan included
the GY modifier for the ambulance transportation. Therefore, we decided that the Plan does not have to pay for
the ambulance transportation billed for date of service October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-autogenous connective tissue graft (D4275 and 
D4285), provided on August 4, 2023. 
 
You asked the Plan to pay for D4275 and D4285. You say that all of this dental work was medically necessary. 
The Plan denied your request. The Plan says the denied dental services are not covered 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. 
 
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 a non-
autogenous connective tissue graft (D4275 and D4285), provided on August 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot walk or transfer without 
supervision. They need SNF services in order to get stronger. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 18, 2023.

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 this testing was not covered on the date of service. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus failed to note that this testing was not covered
until February 17, 2023. Review of the technical assessment as found on the MolDX program website
(https://app.dexzcodes.com/app#!catalogDetailPage) indicates that the technical assessment for SelectMDx was
not effective until February 17, 2023.

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, the testing components billed were not valid until February 17, 2023.
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 genetic testing provided to the enrollee on January
18, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 6, 2023.

You asked the Plan to pay for this testing. The Plan denied your request. The Plan says the technical
component of this testing was not covered on the date of service. Maximus overturned the Plans denial and
stated the testing was medically necessary. The Plan requested a reopen and stated the issue was not medical
necessity. The Plan noted review of the technical assessment found on the MolDX program website
(https://app.dexzcodes.com/app#!catalogDetailPage) indicates that the technical assessment for SelectMDx was
not effective until February 17, 2023.

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 cannot be paid as billed as the technical code reported was not
valid on the date of service. Based on this information, we decided that Medicare rules for payment of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided
to the enrollee on January 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming. 
 
You asked the Plan to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming. 
You say that the requested insertion, subcutaneous cardiac rhythm monitor, including programming is 
medically necessary. The Plan denied your request. The Plan says insertion, subcutaneous cardiac rhythm 
monitor, including programming does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that insertion, subcutaneous cardiac rhythm monitor, 
including programming is covered when the criteria listed in the Medicare rules section of this decision are 
met. 
 
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 insertion, subcutaneous cardiac rhythm 
monitor, including programming. Our reviewer says that the requested insertion, subcutaneous cardiac rhythm 
monitor, including programming is not considered medically reasonable and necessary. Our physician reviewer 
found that while the patient has a history of atrial fibrillation, there is no documentation provided to suggest a 
history of unexplained syncope, cryptogenic stroke or any other apparent indication for an implantable recorder 
(ILR). In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR 
in this patients 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 insertion, subcutaneous cardiac rhythm monitor, including programming have 
not been met. Therefore, we decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac 
rhythm monitor, including programming.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for radiation therapy for the enrollee's thumb.

You asked the Plan to provide coverage for this treatment. The Plan denied your request. The Plan says
radiation treatment is not covered for this condition. Maximus overturned the Plans denial. The Plan requested
a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Medicare does not cover experimental services. The
references made in the previous review were not studies found in the United States. The documentation is
insufficient to support that radiation therapy is medically reasonable and necessary for the enrollee in this case.
Further investigation into the potential role in the treatment of osteoarthritis with modern low-dose radiation is
required. Therefore, we decided that the Plan does not have to provide coverage for radiation therapy for the
enrollee's thumb.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 8, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. CPT code 70496 was paid on another claim. This claim has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 
billed for date of service August 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) billed for date of service June 20, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 drug testing have been met. 
Specifically, the provided order for lab services does not specify the testing to be performed. The billed code 
cannot be verified. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) billed for 
date of service June 20, 2023.