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

 
We decided that the Plan does not have to pay for imaging services provided on October 7, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this code is part of the primary procedure and 
ineligible for separate pay. 
 
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 75774-26-59 is Angiography, selective, each additional 
vessel studied after basic examination, radiological supervision and interpretation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the procedure report describes a transjugular liver biopsy with hepatic, inferior vena cava and right atrial pressure measurements, Splenic 
angiography. Procedure code 75970 includes radiological supervision and interpretation. Therefore, procedure 
code 75774 cannot be verified, as a separate procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on October 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 CDx (81479) provided on May 19, 2022. 
 
You asked the Plan to pay for Guardant360 CDx. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that 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. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx have 
been met. Therefore, we decided that the Plan has to pay for Guardant360 CDx (81479) provided on May 19, 
2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) and ophthalmic biometry (92136) 
provided on November 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and ophthalmic biometry. You say that you are in need of cataract 
surgery, and your husband had the surgery at this same place with the same doctor and did not get a referral. 
You also say that the eye doctor's office never said you needed a referral. The Plan denied your request. The 
Plan says you were seen by an OON specialist, and there is not an approved authorization on file. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam (92004) and ophthalmic biometry 
(92136) provided on November 18, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), and 
immediate denture - maxillary (D5130). 
 
You asked the Plan to pre-approve the complete denture - mandibular and immediate denture - maxillary. You 
say that you desperately need the dentures and have always had issues with your teeth and have lost mostly all 
of your bottom teeth. You also say that you have $2,000 in comprehensive dental coverage to help cover these 
costs. The Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 pre-approve a 
complete denture - mandibular (D5120), and immediate denture - maxillary (D5130).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have a diagnosis of age-related osteoporosis. You were unable to tolerate alendronate due to 
gastrointestinal issues. The documentation does not support that you have tried and failed intravenous 
bisphosphonate therapy (such as zoledronic acid). The documentation does not support that intravenous 
bisphosphonate therapy would likely be less effective and/or likely have adverse effects. Therefore, you do not 
meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found you have COPD, severe obesity, obesity hypoventilation syndrome, and obstructive sleep 
apnea. You were recently hospitalized with acute on chronic hypercarbic respiratory failure requiring 
intubation. After extubatio, you improved on BiPAP. There is no diagnosis of thoracic restrictive disease or 
generalized neuromuscular disease. There are no pulmonary function tests to confirm the diagnosis of COPD or 
assess severity. There is no arterial blood gas analysis done while stable to document chronic carbon dioxide 
(CO2) retention. If that is present,you may benefit from BiPAP during sleep. The average volume-assured 
pressure support (AVAPS) mode can be provided with BiPAP. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. Therefore, you do 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing provided on August 24, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx testing. You say that this testing was medically necessary. 
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 Guardant360 CDx 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 CDx 
testing provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
documentation does not support that Our physician reviewer found the enrollee was recently hospitalized with sepsis and a urinary tract infection. A diagnosis of COPD is mentioned, although there are no pulmonary 
function tests to confirm airways obstruction.  An arterial blood gas was consistent with acute on chronic 
hypercarbic respiratory failure.  There is no diagnosis of thoracic restrictive disease or generalized 
neuromuscular disease.  The patient improved on BiPAP. There is no ABG done while stable to document 
chronic hypercarbic respiratory failure. If that is present, the patient may benefit from BiPAP during sleep as an 
outpatient.  Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
Therefore, the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
tooth #'s 3 and 4 (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you already had two implants placed and 
now you need the other two teeth 3, and 4 placed. You also say that this is very important since you cannot 
each solid food since the pieces you are missing are molars. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 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, certain limitations apply. The record 
shows your benefit for the surgical placement of implant body: endosteal implant was exhausted on date of 
service January 25, 2023. Therefore, we decided that the Plan does not have to pre-approve surgical placement 
of implant body: endosteal implant tooth #'s 3 and 4 (D6010).
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 these services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that there is insufficient documentation supporting that the complexity of your nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, and that there was a reasonable expectation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission to the IRF. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953), and therapeutic parenteral drugs, two or more administrations, different medications (D9612). 
 
You asked the Plan to pre-approve the bone replacement graft and therapeutic parenteral drugs. You say that 
you started the dental series with a different dentist who said you needed five teeth removed and a bone graft 
during the extractions. You also say the dentist referred you to an endodontics and oral surgeon provider since 
the dentist could not perform the work. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 pre-approve a 
bone replacement graft for ridge preservation - per site (D7953), and therapeutic parenteral drugs, two or more 
administrations, different medications (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
supplies (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for PCDs have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Because the base item is not covered, coverage for related supplies is also denied. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
supplies (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from March 7, 
2023, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that these services are 
medically necessary, as the enrollee requires frequent safety checks and cannot function safely in a lower level 
of care. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for an inpatient 
psychiatric admission. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric care. 
Our reviewer says that the Plan's denial of continued services appears appropriate in this case. Our physician 
reviewer found that it was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations 
and was without aggressive behaviors while not showing any acute threats of safety. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, 
auditory or visual hallucinations or abnormal behaviors. It did not appear that active treatment was taking place 
beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. Based 
upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of March 7, 2023, forward, and could be treated in a lesser 
restrictive 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 continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care from March 7, 2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36561, 76937, 77001, 99152, 99153) provided 
on August 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. Medicare 
rules also say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not payable to 
the physician for services provided in the facility setting. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue (36561, 76937, 
77001, 99152) were reimbursed by the Plan on November 17, 2022. Comparison of the two claims shows these 
are exact duplicates. There is no evidence presented to support that the billed items/services were provided 
twice on the same date. Based on this information, we decided that the Medicare rules for the services have not 
been met. 
 
We also find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to 
the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan 
does not have to pay for the services (36561, 76937, 77001, 99152, 99153) provided on August 25, 2022.