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

 
We decided that the Plan does not have to pre-approve a CT scan of the lumbar spine, a CT scan of the cervical 
spine, and a CT scan of the thoracic spine. 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine, CT scan of the cervical spine and a CT scan 
of the thoracic spine. You say that the requested CT scans are medically necessary because you have spine 
stenosis. The Plan denied your request. The Plan says a CT scan of the lumbar spine, CT scan of the cervical 
spine and a CT scan of the thoracic spine is not medically necessary.  
 
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 a CT scan of the lumbar spine, CT scan 
of the cervical spine and a CT scan of the thoracic spine. Our reviewer says that a CT scan of the lumbar spine, 
CT scan of the cervical spine and a CT scan of the thoracic spine is not medically necessary. Our physician 
reviewer found that the enrollee's chart revealed prior cervical spine and lumbar spine surgery including a 
fusion. Although there are no plan film reports on any level of the spine and no neuro deficit, there is a mention 
of old rib fractures unchanged since 2021. However, there are no conservative treatments including physical 
therapy that has been attempted and no reason for a CT request instead of a magnetic resonance imaging in a 
patient with prior fusion surgery. Therefore, the medical necessity of the requested CT scans of the cervical, 
thoracic, and lumbar spine has not been established in the submitted records. 
 
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 CT scan of the lumbar spine, CT scan of the cervical spine and a CT scan of 
the thoracic spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT 
scan of the lumbar spine, a CT scan of the cervical spine, and a CT scan of the thoracic spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the codes are separately billable. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunizations provided on January 03, 2023. 
 
You asked the Plan to pay for immunizations. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for immunizations provided 
on January 03, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs received on November 28, 
2022. 
 
You asked the Plan to pre-approve the self-administered drugs. You say that the medication was given to you 
by an intravenous (IV) and was not a pill that you took. 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 the self-administered drugs 
received on November 28, 2022.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for or waive the copayment for an office visit, X-Rays, and 
chiropractic manipulative treatment provided by a chiropractor on October 25, 2022. 
 
You asked the Plan to pay for or waive the copayment for chiropractic services. You say that you are appealing 
this denial. The Plan denied your request. The Plan says the office visit and X-Rays are not covered when 
performed by a chiropractor, and you pay $20 copayment for each in-network covered chiropractic visit. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules say a plan must disclose to its enrollees in 
clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your 
contract with the Plan clearly says that you must pay $20 copayment for each in-network covered chiropractic 
visit. 
 
The office visit and X-Rays billed are not manual manipulation of the spine. Additionally, you must pay $20 
copayment for the covered chiropractic service. Therefore, we decided that the Plan does not have to pay for or 
waive the copayment for an office visit, X-Rays, and chiropractic manipulative treatment provided by a 
chiropractor on October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81513 for date of service 
February 7, 2023. 
 
You asked the Plan to pay for the laboratory services coded 81513. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
coded 81513 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services coded 81513 for date of service February 7, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home PT services to be provided by an OON provider.  
 
You asked the Plan to pre-approve home PT services provided by an OON provider. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says the service can be provided 
by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home PT services to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services for procedure codes 19285 and 
19301 billed for date of service November 29, 2022. 
 
You asked the Plan to pay for assistant at surgery services. You say that assistant at surgery services were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says assistant at surgery services are 
not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) codes 19285 and 19301. The Medicare Fee Schedule Database contains a surgical 
indicator of 0 for these procedures.  
 
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 assistant at surgery services. Our reviewer 
says that assistant at surgery services are not medically reasonable and necessary in this case. Our physician 
reviewer found that the record provided is insufficient to establish the need for an assistant at surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of assistant at surgery services have not been met. Therefore, we decided that the 
Plan does not have to pay for assistant at surgery services for procedure codes 19285 and 19301 billed for date 
of service November 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service March 1, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the code is not payable as 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 J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this code was billed within 
the global surgery period as a surgery procedure. Without an appropriate modifier, this code is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of code J3490 have not been 
met. Therefore, we decided that the Plan does not have to pay for code J3490 for date of service March 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical shoulder arthroscopy with extensive debridement for 3 or more discrete structures (298323) provided to the enrollee on February 24, 2022.

You asked the Plan to pay for the surgical shoulder arthroscopy with extensive debridement for 3 or more discrete structures. You say that guidelines allow the procedures to be performed and reimbursed when performed on the same shoulder. The Plan denied your request. The Plan says that the code is not supported in the documentation.

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 29823 is surgical shoulder arthroscopy with extensive debridement for 3 or more discrete structures.

Our Medical Director looked at the case file and the reopen request. At issue is payment for the surgical shoulder arthroscopy with extensive debridement for 3 or more discrete structures. Our Medical Director states that the documentation in the Operative Report does not support extensive debridement of 3 or more discrete structures where no other work was performed. Our Medical Director found that the record does not support procedure code 29823 was performed.

We looked at the Medicare Director's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical shoulder arthroscopy with extensive debridement for 3 or more discrete structures have not been met. Therefore, we decided that the Plan does not have to pay for the surgical shoulder arthroscopy with extensive debridement for 3 or more discrete structures (298323) provided to the enrollee on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #26 and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says the tooth does not show that at least 50% of the tooth is 
lost; therefore, the requested dental services are not medically necessary. 
 
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 the dental 
services. 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 the dental services. Our reviewer says 
that the criteria for coverage for a crown restoration (D2740) and mandibular removable partial denture 
(D5214) have not been met. Our physician reviewer found that the documentation provided was not complete. 
Diagnostic radiographs were not provided. As a result, a determination of the criteria for coverage could not be 
made. 
 
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 the dental services. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth #26 and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a prosthetic leg with a computerized knee and advanced foot with ankle and other parts (L5856, L5828, L5845, L5848) for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that that the notes do not support the need for a microprocessor knee instead of a mechanical knee. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional records for review.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a prosthetic leg with a computerized knee and advanced foot with ankle and other parts (L5856, L5828, L5845, L5848). Our Medical Director states that the limited available documentation supports that the enrollee in this case needs a microprocessor knee. LCD L33787 states, "It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications." This caveat applies to the enrollee in this case. The enrollee's physical medicine and rehabilitation physician documents that a microprocessor knee is medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the enrollee's condition meets 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a prosthetic leg with a computerized knee and advanced foot with ankle and other parts (L5856, L5828, L5845, L5848) for the enrollee. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records show medical necessity. The Plan 
denied your request. The Plan says the testing is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The records show that panel testing of more than 5 targets was provided. 
Respiratory pathogen panel tests for greater than 5 respiratory pathogens are not medically reasonable and 
necessary. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service December 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 28, 2023. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of a computed tomography (CT) scan
provided to the enrollee on August 05, 2022, and billed under Claim A.
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 for
insufficient information in the case file. The Plan requested a reopen and demonstrated that the previous claim
history show the enrollee received code 71250 on August 5, 2022, under claim number Claim B. The provider
then billed code 71250 a second time for the same date of service under Claim A, which resulted in the
claim being denied a duplicate.
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, Claim A appears to be a direct duplicate of the previously billed and paid
Claim B, which no modifier to indicate this was a separate and distinct service. Medicare rules for coverage of
this service have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation
of a computed tomography (CT) scan provided August 05, 2022, and billed under Claim A.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 13, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you had a heart attack and was not in 
control of what was going on. The Plan denied your request. The Plan says self-administered drugs do not fall 
under Medicare Part B coverage. 
 
  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 pay for self-administered drugs provided 
on January 13, 2023.  
 
Benefits for self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 20, 2023, to 
January 21, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the only drugs you used were what was 
given to you in the emergency room. The Plan denied your request. The Plan says self-administered drugs do 
not full under Medicare Part B coverage. 
 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 pay for self-administered drugs provided 
on January 20, 2023, to January 21, 2023.  
 
Benefits for self-administered drugs 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: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. You say that a contract has not been obtained to have access to 
Privigen. The Plan denied your request. The Plan says that the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract does not indicate that it has implemented such criteria for 
certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan has to pre-approve Gamunex-C.  
 
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.