Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 You asked the Plan to pre-approve Ocrevus. 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 Ocrevus. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has Multiple Sclerosis. The documentation does not support that the enrollee has tried and 
failed Kesimpta. The documentation does not support that Kesimpta would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does 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 Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HBO therapy (99183, G0277). 
 
You asked the Plan to pre-approve HBO therapy. You say that the requested services are a medical necessity 
for the enrollee. 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 HBO therapy. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is coverage of HBO therapy for soft-tissue radionecrosis of the bladder. HBO 
therapy is eligible for coverage for soft-tissue radionecrosis as an adjunct to conventional treatment. However, 
it is unclear in this case that the enrollee has radionecrosis, especially since the cystoscopy showed that the 
bladder neck was spared from inflammatory changes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve HBO therapy (99183, G0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator on 
April 11, 2023, to May 11, 2023.  
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 a 20% 
coinsurance for Medicare-covered benefits for durable medical equipment (DME). 
 
You have been asked to pay a 20% coinsurance for an automatic external defibrillator. This item/service falls 
within the durable medical equipment (DME) and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $1,339.60 ($3,348.99 allowed 
amount x 20% = $669.80 [$669.80 coinsurance x 2 visits = $1,339.60]). Therefore, we decided that the Plan 
does not have to waive the coinsurance for an automatic external defibrillator on April 11, 2023, to May 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a microprocessor knee (L5848, L5845, L5828,
L5856, L5925), multi-axial rotation unit (L5986), and flex-walk system or equal (L5981) for the enrollee.

You asked the Plan to provide coverage for a microprocessor knee (L5848, L5845, L5828, L5856, L5925),
multi-axial rotation unit (L5986), and flex-walk system or equal (L5981). You say that at the time of the
appeal, these prosthetic components were medically necessary for the enrollee. The Plan denied your request.
The Plan says the medical records provided do not support the statements by the prosthetist. Maximus
overturned the Plans denial. The Plan requested a reopen and noted that the codes requested are considered as
one unit. The Plan also states the enrollee's physician documents the enrollee has K3 ambulation potential, and
there is no reason why a microprocessor knee is medically necessary. The Plan notes the prosthetist is the
vendor and therefore has financial interest in the outcome of the claim. There is a signed physician order for a
microprocessor knee, but the office visit note makes no mention of enrollee requiring features that are not
available with a mechanical knee. A prescription is not considered to be part of the medical record. Medical
information intended to demonstrate compliance with coverage criteria may be included on the prescription but
must be corroborated by information contained in the medical record. The requested microprocessor knee
exceeds the enrollee's need and is not reasonable and necessary per Medicare criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met.

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 a microprocessor knee (L5848, L5845,
L5828, L5856, L5925), multi-axial rotation unit (L5986), and flex-walk system or equal (L5981) have been
met. Therefore, we decided that the Plan does not have to provide coverage for a microprocessor knee (L5848,
L5845, L5828, L5856, L5925), multi-axial rotation unit (L5986), and flex-walk system or equal (L5981) for
the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
April 2, 2023, through April 14, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
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 pay for these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on March 30, 2023 with Major 
Schizoaffective Disorder Unspecified Type. Based upon the review of the records provided, it was not expected 
this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal 
or homicidal ideation, or visual hallucinations, but did have auditory hallucinations. The enrollee was 
compliant with treatment while not showing any acute threats to 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 she did not have dangerousness to self or others and was compliant with 
her treatment. The health plans denial of continued inpatient psychiatric services is appropriate. This enrollee 
did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger 
to herself or others and did not have visual hallucinations but did have auditory hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services were 
reasonably expected to improve the enrollees condition or were for the purpose of a diagnosis beyond the date 
in question. It did appear that the records were supervised and evaluated by a physician. Based upon the review 
of the records provided, the enrollee did not meet the criteria for coverage of the acute inpatient psychiatric 
hospital care provided from April 2, 2023 forward as this enrollee was not shown to be a danger to herself or 
others and did not have delusions, or visual hallucinations. She was cooperative/compliant with treatment while 
not showing any threats to safety. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from April 2, 2023, through April 14, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on April 20, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the provider is a participating provider with the 
Plan. Please reprocess the claim according to your agreement. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 outpatient office visit (99214) provided on 
April 20, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service is payable under Medicare guidelines. 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial or failure of bilevel positive 
airway pressure (BIPAP) documented. Should the enrollee require average volume-assured pressure support 
(AVAPS), this can be delivered with BIPAP and trial if the enrollee has an appropriate response as initial 
therapy. This would be considered best practice. Hence, documentation does not support home ventilator. 
 
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 (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hematocrit test (85014) provided on May 16, 2023. 
 You asked the Plan to pay for 85014. You say that the lab does not have access to physician's notes or reports. 
The Plan denied your request. The Plan says the record references a different lab identifier than the claim form, 
so the place the service was performed cannot be verified. 
 
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 85014 is blood count, hematocrit. 
 
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 85014. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found there is no order from a provider requesting code 85014. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 85014 have not been met. Therefore, we decided that the Plan does not have to 
pay for hematocrit test (85014) provided on May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of a ventilator. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use with very low set tidal volumes (150 to 200 milliliters) 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with average 
volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) (78452). 
 
You asked the Plan to pre-approve MPI. 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 stress testing with cardiac imaging will be considered 
medically reasonable and necessary under certain conditions. 
 
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 MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no evidence provided that would 
support the need for radionuclide stress testing at this time. In summary, there is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing in this enrollee's 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 MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI) (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90999 billed for April 20, 2023, to April 21, 
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 supported. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 90999 has an OPPS status indicator of B. This 
means that the code is not recognized for payment. Therefore, we decided that the Plan does not have to pay for 
procedure code 90999 billed for April 20, 2023, to April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0482 for date of service April 4, 2023. 
 
You asked the Plan to pay for code G0482. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that drug testing is only covered for certain indications. 
 
We find that CPT code G0482 is not payable as billed. Specifically, ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
Based on this information, we decided that Medicare rules for coverage of code G0482 have not been met. 
Therefore, we decided that the Plan does not have to pay for code G0482 for date of service April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 24, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cologuard test provided to the enrollee on December 19,
2022.

You asked the Plan to pay for the Cologuard test. You say that this claim should be covered. The Plan denied
your request. The Plan says that the frequency limit for this service has been exceeded. Maximus overturned
the Plan's denial for lack of information. The Plan requested a reopening and stated that the enrollee had
already had this exam within three years of this date of service. The Plan is correct in this case. Medicare rules
states that the Cologuard test is covered once every three years for Medicare beneficiaries. The Plan has
provided documentation to show the enrollee had a Cologuard test on February 13, 2020, which is less than
three years from December 19, 2022. Therefore, we decided that the Plan does not have to pay for the
Cologuard test provided to the enrollee on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing billed with codes 81455 and 81456 for 
date of service May 16, 2023.  
You asked the Plan to pay for the genetic testing billed with codes 81455 and 81456. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing billed with codes 81455 and 81456 at issue were requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the genetic testing billed with codes 81455 and 81456 for date of service May 16, 2023.