Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
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 the enrollee has just finished 12-months of therapy and 
you would like to move the enrollee to Prolia instead of Zoledronic due to their past kidney transplant. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred medications 
Pamidronate or Zoledronic. 
 
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 
service is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Pamidronate 
or Zoledronic acid before they will approve the requested drug. The enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plan's required drugs would likely be 
less effective or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto.  Benefits for Xarelto 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 31, 2022, to August 
16, 2022. 
 You asked the Plan to pay for the home health services. You say that you were not aware that the NOA had not 
been received. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 1, 2022. The NOA was not received by the Plan until April 10, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
July 31, 2022, to August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on July 10, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 37253 rendered on June 20, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that procedure code 37253 is not supported by the medical records submitted. 
 
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 37253 is "Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic 
intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List 
separately in addition to code for primary procedure)." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that there is satisfactory documentation 
that billing for a single instance of CPT code 37253 is justified as the service has been rendered. There is 
satisfactory documentation that intravascular ultrasound (IVUS) was used to interrogate the aorta (billed and 
covered as 37252) and the left common/external iliac arteries. There is documentation of IVUS findings, 
distinguishing the true lumen from the false lumen (very difficult to determine on angiography essential 
requiring IVUS). As the common iliac artery and external iliac artery are considered a single vessel for the 
purpose of IVUS billing, coverage of a single instance of 37253 is recommended. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 37253 rendered on June 20, 2023.  
 
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 genetic testing provided on June 12, 2023. 
 
You asked the Plan to pay for genetic testing. You say that this testing meets the requirements for coverage. 
The Plan denied your request. The Plan says this testing was not billed with the appropriate Place of Service 
(POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. This claim was billed with POS code 81  indicating an independent 
lab setting  however, the records do not support that the sample for this testing was taken directly in the 
independent laboratory. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided 
on June 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
18, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are being billed a 
different copay. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 copayment for the ambulance 
services provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on September 7, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0260 provided on July 25, 2023. 
 
You asked the Plan to pay for procedure code G0260. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital outpatient departments should report 
code G0260 for sacroiliac joint injections. G0260 should be reported with an imaging code specific to the 
imaging modality employed. 
 
We looked at the file and Medicare rules. The claim was not billed with an appropriate imaging code. Based on 
this information, we decided that Medicare rules for coverage of procedure code G0260 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0260 provided on July 25, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 You asked the Plan to pre-approve Vabysmo. You say that the request is medically necessary. The Plan denied 
your request. The Plan says 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 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 Vabysmo. Our reviewer says that the 
criteria for coverage of Vabysmo have not been met. Our physician reviewer found the Plan requires a trial of 
Byooviz before they will approve the requested drug. The enrollee has not tried and failed Byooviz. The 
enrollee is documented to have used Avastin in the past. Byooviz is a biosimilar of the drug ranibizumab, 
which is approved by the Food and Drug Administration (FDA) for the treatment of the enrollee's condition. 
Biosimilar medications show similar efficacy and safety to the original medication. The American Academy of 
Ophthalmology states that ranibizumab is an effective treatment for exudative age-related macular 
degeneration. The required step-therapy of the Plan's required drug Byooviz would not likely be less effective 
or 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J2777).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calreticulin Exon 9 Mutation Detection, Jak2 Exon 12
Mutation Analysis and MPL Mutation Analysis (81403, 81219, 81402) for the enrollee.

You asked the Plan to pre-approve the genetic testing. You say that there is no medical necessity needed to test
for BCR-ABL. The Plan denied your request. The Plan says that the requested genetic testing does not meet the
requirements for approval.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for genetic testing.
Our Medical Director states that the enrollee was referred to hematology for evaluation of chronic leukocytosis
and polycythemia. The hematologist wrote that the mild polycythemia was "most certainly secondary to
chronic tobacco use. In addition, he was tested for sleep apnea five years ago and this may certainly have
progressed, though tobacco use is the most likely culprit." Molecular testing was ordered for JAK2, MPL, and
CALR. The clinical documentation does not support that the coverage criteria for the genetic testing were met
in this case. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of the
genetic testing.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does
not have to pre-approve Calreticulin Exon 9 Mutation Detection, Jak2 Exon 12 Mutation Analysis and MPL
Mutation Analysis (81403, 81219, 81402) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 18, 2023, and billed 
with codes 87481, 87491, 87500, 87591, 87640, 87641, 87653, 87661 and 87798. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on May 18, 2023, and billed with codes 87481, 
87491, 87500, 87591, 87640, 87641, 87653, 87661 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99213 and the injections described by 2 units of code J7324 billed on June 9, 2023. 
 
You asked the Plan to pay for 99213 and J7324. You say that 99213 and J7324 should be paid as billed because 
they are supported in the documentation. The Plan denied your request. The Plan says 99213 is denied because 
payment for this service is bundled into payment for the minor procedure performed on the same date. J7324 is 
denied because the units billed exceed the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -25 is used to report circumstances 
where the enrollee's condition requires a significant, separately identifiable evaluation and management service 
above and beyond the usual care associated with the procedure that was performed by the same provider on the 
same date. The rules also say that claims submitted where the units of service exceed the MUE value cannot be 
paid when the MAI value is 2. 
 
We looked at the file and Medicare rules. In this case we confirmed that 99213 was billed with on the same day 
as the minor procedure coded as 20610 billed by the same provider. We confirmed that modifier -25 was not 
appended to 99213. Modifier -25 is required to report a separate and identifiable evaluation and management 
service for which separate payment is requested on the same day as a minor procedure. Regarding code J7324, 
the MUE for J7324 is 2. The MAI value for this code is 2. You billed 4 units of this code, exceeding the MUE. 
Based on this information, we decided that Medicare rules for coverage of 99213 and J7324 have not been met. 
Therefore, we decided that the Plan does not have to pay for the evaluation and management services described 
by code 99213 and the injections described by 2 units of code J7324 billed on June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a continuous glucose monitor (CGM) for the
enrollee.

You asked the Plan to provide coverage for this equipment. You say that this equipment is medically necessary.
The Plan denied your request. The Plan says the required Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit
with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not meet all of the
required coverage criteria for this equipment. Medicare rules for coverage of this equipment have not been met.
Therefore, we decided that the Plan does not have to provide coverage for a continuous glucose monitor
(CGM) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76882) of soft-tissue and masses provided on 
April 21, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says the medical records do not support code 76882. Therefore, code 
76882 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 76882 is ultrasound, limited, joint or focal evaluation of 
other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other 
soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation. 
 
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 ultrasound. Our reviewer says that CPT code 76882 is not 
supported, and there is a more appropriate code for the vascular ultrasound that was performed. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound (76882) of soft-tissue and masses provided on April 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 6, 
2023, to June 21, 2023. 
 
You asked the Plan to pay for the SNF care. You say that the service should be covered under the Medicare 
Act.  The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay from 
June 6, 2023, to June 21, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from June 6, 2023, to June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gel footplate covers and BodiLink head support 
hardware. 
 
You asked the Plan to pre-approve the gel footplate covers and BodiLink head support hardware. You say that 
this is medically necessary for the enrollee. The Plan denied your request. The Plan says these items do not 
serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve gel footplate covers and BodiLink head support hardware.