Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided from April 05, 2022, through April 08, 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. The Plan noted that per OCE Quarterly Release Files Integrated OCE (IOCE) CMS Specifications V23.0 Effective January 01, 2022, OCE edit 50 Edit Description under "Non-covered under any Medicare outpatient benefit" revenue code 0637 was listed under statutory exclusion and the status indicator is E and E1 which is a non-allowed item or service. The billed services for April 05, 2022, through April 08, 2022, denied correctly as revenue code 0637 has a status indicator of "E" and "E1" indicating a nonallowed item or service.
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 code.
In this case, this claim could not be paid as billed due to an issue with the reported revenue code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided from April 05, 2022 through April 08, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for FoundationOne Liquid CDx test (0239U) provided July 6, 2022.
You asked the Plan to pay for this claim . You say that the Plan should pay this testing. 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 stated that Maximus did not apply the correct billing criteria. The Plan notes that while they agree, the blood specimen may have been obtained in a hospital setting, the claim form listed the place of service (POS) as 81, Independent Laboratory, independent of an institution or a physician's office. The claim form contradicts the reasoning used by Maximus to overturn the denial. The laboratory billed POS as 81. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively. The date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected with 3 exceptions. Maximus references the exceptions regarding a ADLT collected from a hospital outpatient during an encounter. There is no documentation of molecular pathology testing performed on a specimen collected during an outpatient encounter billed for July 6, 2022, and POS 81.
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 errors with the dates of service reported and the POS code billed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne Liquid CDx test (0239U) provided July 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve the continuation of SNF care. You say that you need additional time to 
recover. You say you still need help going to the bathroom and do not have help at home. The Plan denied your 
request. The Plan says the continuation of SNF care 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 the continuation of 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 you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that these claims should be covered. The Plan 
denied your request. The Plan says there was insufficient information provided for review. 
 
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 laboratory services have been met. 
In this case medical records were required to review medical necessity. The Plan sent requests for this missing 
information but the information was not received. Without medical records we are unable to review whether these services were medically necessary. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation of a trial of a 
back brace. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code J3490 billed to the enrollee for date of service October 27, 2022.
You asked the Plan to pay for this service . 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 stating the code was valid. The Plan requested a reopen and demonstrated that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 27096 that was billed on the same claim. Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service. Per the above Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion 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, payment for code J3490 in this case was included in the payment for the administration and infusion services. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code J3490 billed to the enrollee for date of service October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve mandibular partial denture. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says for this service to be approved the tooth must have a 
good long-term outlook. Based on the pictures/x-rays/notes that the member's dentist sent in there is no proof 
that this tooth will have a good long-term outlook. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers mandibular 
partial denture when the services are medically necessary and reasonable.  
 
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 mandibular partial denture. Our reviewer says that the service is not medically necessary. Our physician reviewer found the review of the 
documentation indicates that the only tooth present in the oral cavity is #17. This tooth would not make a good 
partial abutment. The more reasonable treatment would be a complete mandibular denture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of mandibular partial denture have not been met. Therefore, we decided that the 
Plan does not have to pre-approve mandibular partial denture (D5214).
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 enrollee currently meets full IRF criteria, and the 
enrollee's needs cannot be safely met by skilled nursing or home health because they require direct physician 
supervision and management. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home 
with home health services, or home with outpatient therapy. 
 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 was admitted for anemia and gastrointestinal bleeding. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion, 
represented by code 27279. 
 
You asked the Plan to pre-approve minimally invasive percutaneous SI fusion. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 minimally invasive percutaneous SI 
fusion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has diagnoses of diagnoses of chronic low 
back pain, post laminectomy syndrome, right hip pain, right SI joint pain and sciatica. Minimally invasive SI joint fusion is experimental for back pain. More research is needed. Therefore, the enrollee does not meet 
criteria for the requested 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 minimally invasive percutaneous SI fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion, 
represented by code 27279.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
November 22, 2022, and December 22, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like these TENS 
supplies to be reprocessed, as medical necessity has been met. The Plan denied your request. The Plan says the 
denial for the TENS electrical stimulator supplies, 2 leads, was appropriate. 
 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 electrical stimulator supplies have 
been met. Specifically, the records do not show there was a refill request from the enrollee. Therefore, we 
decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on November 
22, 2022, and December 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 Dupixent.   
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. 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 transurethral waterjet ablation of prostate is covered 
when specific criteria 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 transurethral waterjet ablation of 
prostate. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not meet the coverage criteria detailed in the LCD. Specifically, transurethral waterjet ablation of 
prostate is not considered reasonable and necessary in patients with known or suspected prostate cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for services coded as J3490 billed to the enrollee for September 27, 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 Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that The unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 27096 that was billed on the same claim. Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service. Per the Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion 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 code J3490 could not be paid as billed as it is not appropriate to bill it separately in this treatment setting. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for services coded as J3490 billed to the enrollee for September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on May 19, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned stating the Plan did not use the correct Medicare criteria and should have used Medicare Local Coverage Determination (LCD) MolDX: ConfirmMDx Epigenetic Molecular Assay(L36327). The Plan requested a reopen and stated that per LCD L36327, the enrollee does not meet criteria for this testing. The Plan noted that per LCD L36327 this testing is covered when a patient is being considered for a repeat biopsy due to persistent or elevated cancer risk factors. The medical records show the PSA level was 5.2 on April 12, 2022, and the tissue biopsy was collected on May 19, 2022. No updated PSA was obtained to detect elevated risk factors.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. Based on the medical records provided, the enrollee did not meet clearly meet those criteria at the time the testing was performed. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gender reassignment surgery. 
 
You asked the Plan to pre-approve gender reassignment surgery. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the documentation does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. No medical records were provided. The Plan requested medical 
records from your provider various times without response. Without medical records, this means the case file 
does not include the necessary documentation to support medical necessity of this procedure. Based on this 
information, we decided that Medicare rules for coverage of gender reassignment surgery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve gender reassignment surgery.