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

 
We decided that the Plan does not have to pay for  the DecisionDx-SCC test (0315U) provided on March 10, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for  the DecisionDx-SCC test (0315U) provided on 
March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2023. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. 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 an office visit provided 
on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor system 
(CGM) (receiver, transmitter, and sensor) (A4239). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. The Plan denied your request. The Plan says as you 
are not on insulin and do not have documentation of problematic hypoglycemia, a CGM is not covered under 
current Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor system (CGM) (receiver, transmitter, and sensor) (A4239).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says enrollees must receive their care from a 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 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 
items/services 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 lab services provided on February 16, 2023, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve hospital bed. You say that the enrollee has open wounds, and you have to 
dress their legs which is a 2-to-3-hour process. For you to be bent over the bed is taking a toll on your spine. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca (Q5111). 
 You asked the Plan to pre-approve Udenyca. You say that the enrollee's treatment with Udenyca is medically 
appropriate and necessary and should be covered and a reimbursed service. The Plan denied your request. The 
Plan says the enrollee does not have any stated contraindications to the preferred products, nor have they tried 
any of the preferred agents. The Plan also says that a rationale was not provided for use of the non-preferred 
product for safety or efficacy. 
 
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 Udenyca. Our reviewer says that the 
enrollee does not meet the coverage criteria for Udenyca. Our physician reviewer found the Plan requires a trial 
of Fulphila, Neulasta, or Neulasta Onpro before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drug(s). Our reviewer also found that there is no documentation provided 
indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca (Q5111).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 1, 
2022, to August 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 1, 2022, to August 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance mileage (A0425) provided on April 18, 2022. 
 
You asked the Plan to pay for ambulance mileage. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the units of service billed exceed 
what is permitted on a single claim line for this code. 
 The Plan must follow Medicare rules. Medicare rules say that claim lines submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 1. If a code has an MAI of 1, appropriate use of 
a modifier may be used to report the same code on separate lines of the claim, and each line for that code will 
be separately evaluated against the MUE value for that code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 318 units of 
this code on a single line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance mileage (A0425) provided on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 24, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81335, 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 24, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81335, 81355.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation to avoid recurring 
emergency room visits due to falls at home. You say your doctor requires you to have three hours of physical 
therapy a day five times a week. The Plan denied your request. The Plan says that the IRF services you are 
requesting do not meet the requirements for approval.  
 
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 found to be medically reasonable and necessary. Our physician reviewer found your 
condition is complex and fragile, and there is every reason to expect that you will participate in and benefit 
from physical and occupational therapy, physician oversight of polypharmacy and kidney function, and case 
manage coordination of any additional services you might need to make your current living arrangements 
sustainable and avoid preventable admissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided 
on February 16, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not 
support the billing of procedure codes 96365, 96366, 96521, and J1817. 
 
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 96365 is Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is Refilling and maintenance of portable pump. The definition of code J1817 is Insulin for administration through dme (i.e., 
insulin pump) per 50 units. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate code than 96365, 96366, and 96521 for these services. The file shows that Novolin R was 
administrated intravenously as part of OIVIT and there is a more appropriate code for this service. 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 procedure codes 96365, 96366, 96521, and J1817 provided 
on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on February 15, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that this provider is covered under the patient's 
benefit plan. The Plan denied your request. The Plan says telehealth is not a covered service when done with 
out-of-network. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that telehealth services are not a covered benefit  
out-of-network. Based on this information, we decided that Medicare rules for coverage of the telehealth 
services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on February 15, 2023.
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 will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says the request for IRF services does not meet the requirements for approval.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the additional services provided on 
January 13, 2023, by an OON provider.  
 
You asked the Plan to pay for the office visit and the additional services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services were not authorized. 
 
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 office visit and the additional services 
provided on January 13, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 36620 billed for date of service April 4, 
2023. 
 
You asked the Plan to pay for procedure code(s) 36620. The Plan denied your request. The Plan says this code 
was billed with an invalid modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 0 for CPT code(s) 36620. This 
identifies codes that describe physician services. The concept of a professional component and a technical 
component (PC/TC) does not apply since physician services cannot be split into professional and technical 
components. Modifiers 26 and TC cannot be used with these codes. Based on this information, we decided that 
Medicare rules for coverage of procedure code 36620 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 36620 billed for date of service April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93280 billed for date of service October 4, 
2022. 
 You asked the Plan to pay for procedure code 93280. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93280 is bundled into payment for code 33208. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93280 
is a column II code to column I code 33208. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93280 billed for date of service October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient rehabilitation services provided from May 19, 2022, to May 31, 2022.
You asked the Plan to waive the copayment for the outpatient rehabilitation services. You say that you disagree with the copayment. The Plan denied your request. The Plan says that this cost sharing was charged correctly.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home and community-based services). These services qualified under the Medicaid coverage. The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient rehabilitation services provided from May 19, 2022, to May 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to pay for code (J7999) provided to the enrollee on December 1, 2022.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and demonstrated that claim was billed without the KD modifier which shows as drug or biological infused through durable medical equipment.
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 and when necessary, the appropriate modifier. Review of the claim submitted shows the claim did not include the required KD modifier. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for the services (J7999) provided to the enrollee on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the methylprednisolone acetate injection provided on December 13, 2022.
You asked the Plan to waive the coinsurance for the methylprednisolone acetate injection. You say that the claim was processed correctly. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria. The Plan is correct in this case. Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of $1.45 for the methylprednisolone acetate injection. This item/service falls within the Medicare Part B prescription drugs 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. Therefore, we decided that the Plan does not have to waive the coinsurance for the methylprednisolone acetate injection provided on December 13, 2022.