Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the triamcinolone acetonide provide on March 13, 2023. 
 
You asked the Plan to pay for the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 pay for the medication. Our reviewer says that the 
request is medically necessary. Our physician reviewer found that the record indicates that the enrollee has a 
diagnosis of osteoarthritis of the knees and has had efficacy from previous injections of the requested service. 
The Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved drug compendia do not contain a prohibition against repeat administration of the 
requested drug. The record provided is sufficient to establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. 
 
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 medication have been met. Therefore, we decided that the Plan has to pay 
for the triamcinolone acetonide provide on March 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anterior cervical discectomy and fusion (ACDF) C6-7, 
remove anterior plate C5-6, and with Allograft Vivigen (20930, 22551, 22845, 22853). 
 
You asked the Plan to pre-approve ACDF C6-7, remove anterior plate C5-6, and Allograft Vivigen. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 ACDF) C6-7, remove anterior plate C5-
6 with Allograft Vivigen. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested anterior cervical discectomy and fusion (ACDF) at C6-7, removal of anterior plate at C5-6, and 
ViviGen allograft is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ACDF) C6-7, remove anterior plate C5-6 with Allograft Vivigen have not been 
met. Therefore, we decided that the Plan does not have to pre-approve anterior cervical discectomy and fusion 
(ACDF) C6-7, remove anterior plate C5-6, and with Allograft Vivigen (20930, 22551, 22845, 22853).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic imaging (D0210) provided 
on June 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 requested item or service was exhausted on date of service August 20, 2020. 
Therefore, we decided that the Plan does not have to pay for a complete series of radiographic imaging 
(D0210) provided on June 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ferric carboxymaltose injection, 1 mg (J1439).  
 
You asked the Plan to pre-approve the injection. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has a diagnosis of iron deficiency anemia. The 
record does not indicate that the enrollee has an intolerance to oral iron. The Food and Drug Administration has 
not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The record does not document the existence of a condition enumerated under the rules for which 
coverage is available. The elements of the coverage criteria are not satisfied.  The requested service cannot be 
recommended. 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ferric carboxymaltose injection, 1 mg (J1439).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for endoskeletal ankle foot system,
microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973).

You asked the Plan to provide coverage for this equipment. You say that at the time of the appeal, this
equipment was medically necessary. The Plan denied your request.

The Plan says Medicare coverage criteria were not 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 an endoskeletal
ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes
power source (L5973). The Maximus Physician Reviewer determined that criteria were met for the requested
items. The reviewer found that the prosthetist amply and credibly explained the treatment rationale in choosing
the foot in question for this very active enrollee. Additionally, there has been a change in the physiological
condition of the enrollee (significant weight loss) and the enrollee is a K3 ambulator.

The Plan requested a reopen and argued that there is no objective evidence in the medical record to show why
mechanical feet cannot be used. Review of the medical records shows the enrollee has
diabetes, who underwent a right below-knee amputation. It is reported that he works in a large
retail environment which requires him to be on his feet all day, carrying heavy objects. The enrollee lost weight, leading to an ill-fitting socket, and causing the prosthetic foot to be too stiff for his weight. Therefore,
has a replacement socket and a microprocessor-controlled foot have been requested. The Plan is correct in this
case. The available clinical documentation does not support that the coverage criteria for an endoskeletal ankle
foot system with a microprocessor-controlled feature were met in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not
have to provide coverage for endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion
and/or plantar flexion control, includes power source (L5973).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87798, 87801) provided on July 15, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 87481, 87798, & 87801 is not supported in the medical record. Specifically, multiple 
unbundled codes were billed for a single panel. 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 lab 
services (87481, 87798, 87801) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 22, 2023, billed with 
procedure code J3490. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the service at issue was not billed with the 
required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 64483 
provided on June 2, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
June 22, 2023, billed with procedure code J3490.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided on May 9, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that this service should be covered. The 
Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are not 
covered under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) 
provided on May 9, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is 
in an assisted living facility on outpatient medications with no issues that appear to require a physicians 
evaluation three or more times per week in a hospital setting. The enrollee does require physical therapy and 
occupational therapy services, but the medical records provided do not clarify why the enrollee requires an 
intensive inpatient rehabilitation therapy program. The enrollee is ambulating 85 feet without an assistive 
device. Provided medical records do not support that the intensive inpatient rehabilitation therapy program is 
necessary and that therapy at a lower level of care such as care in the assisted living facility with home health 
services or in a skilled nursing facility is not appropriate 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Colorectal cancer screening; fecal occult blood test (G0328) 
provided June 8, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you needed a second test a few weeks after 
your first one. The Plan denied your request. The Plan says the benefit for this laboratory service has been 
exhausted. 
 The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees are eligible for coverage of a Guaiac-based fecal occult blood test (gFOBT) or a 
fecal immunochemical test (FIT) once every 12 months. 
 
You have been asked to pay $64 for the laboratory service. The records show that this service was provided on 
May 21, 2023, which is less than 12 months prior to the visit at issue in this case. Therefore, this benefit is 
exhausted. The laboratory service falls within the Colorectal cancer screening 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 pay for Colorectal cancer screening; fecal occult blood test (G0328) provided June 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313),
expandable controller (E2377), gel pads (K0108), and transfer handles (K0108).

You asked the Plan to pre-approve these items. You say that these electronics are necessary for the power
wheelchair The Plan denied your request. The Plan says that the electronic connection, expandable controller
and expandable controller harness cannot be covered as it is not medically necessary to control the three
approved power options through the joystick (drive interface). The Plan also says the gel pads and transfer
handles serve no medical purpose and cannot be approved.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection, harness, expandable controller, gel pads and transfer handles. Our Medical Director states that
clinical documentation supports that the enrollee's upper extremity strength and function are adequate to be
able to control the power options using their own switches. There is no documented medical need to control the
power options through a joystick. The clinical documentation does not support that gel pads and transfer
handles are medically reasonable and necessary for this enrollee. Our Medical Director found that the enrollee's
condition does not meet criteria for coverage of these items.

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 items have not been met. Therefore, we decided that the Plan does not
have to pre-approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), gel
pads (K0108), and transfer handles (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (88120) provided on August 23, 2022. 
 You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test is for screening purposes and is non-covered. 
 
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 test at issue in this appeal, UroVysion, was 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 lab 
testing (88120) provided on August 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Ketamine infusion rendered from May 11, 2023, to May 
17, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is experimental and therefore not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 services. Our reviewer says that the 
requested servicers are not medically reasonable or necessary. Our physician reviewer found that based on a 
review of the records and the literature, the infusion is not indicated by the FDA for the treatment of depressive 
disorders. The use of this procedure is considered off-label. It would be considered experimental and 
investigational, and not medically necessary.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a Ketamine infusion rendered from May 11, 2023, to May 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 26, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that 71045 should be paid as billed because the 
enrollee has multiple exams on the same date of service. The Plan denied your request. The Plan says payment 
for code 71045 is bundled into payment for code 71046. 
 
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 71045 
is a column II code to column I code 71046, which was billed on the same date of service by a physician of the 
same specialty in the same group, which is considered the same provider. 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 71045 billed for date of 
service May 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does not need an LTACH 
level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with bacteremia following recent orthopedic surgery. The 
record indicates that the enrollee is improving but still requires acute care services before transitioning to a 
lower level of care. Our reviewer found that the enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that they are not 
currently receiving but that would be available at the LTACH facility. Our physician reviewer also found that 
the elements of the coverage rules are not satisfied, and the requested service cannot be recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.