Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15734 rendered on January 9, 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 there is no documentation that the appealed procedure CPT 15734 was performed. 
 
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 15734 is "Muscle, myocutaneous, or fasciocutaneous 
flap; trunk." 
 
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 not supported by the medical records. Our reviewer found that the medical record includes an abdominal/pelvis computed tomography (CT) and emergency department visit; however, a procedure report for 
the procedure billed was not found. Therefore, this procedure code cannot be verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 15734 rendered on January 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided to the enrollee
on July 27, 2021.

You asked the Plan to pay for the imaging services. You say that the claim was billed correctly and should be
paid. The Plan denied your request. The Plan says that documentation does not support the billed code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services
performed.

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 described by procedure code(s). Our reviewer says that documentation does not support the billed code. Our physician reviewer
found the medical records provided do not include sufficient documentation to validate that short-latency
somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the
central nervous system; in the trunk or head was performed independent of the Somatosensory evoked
potentials of the ulnar nerve that was also performed, therefore this procedure cannot be
verified.

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 imaging services have not been met. Therefore, we decided that the Plan
does not have to pay for the imaging services provided to the enrollee on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance (eg, proton) imaging, brain 
(including brain stem); without contrast material, followed by contrast material(s) and further sequences 
(70553) provided May 22, 2023, by an out-of-network provider. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this provider is out-of-network, the services were not referred by a network provider, and the 
services were not urgent or emergent, nor were they approved in advance. 
 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 magnetic resonance (eg, proton) imaging, 
brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences 
(70553) provided May 22, 2023, by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (DermTech melanoma test) performed on August 2, 
2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee underwent DermTech Melanoma test that differentiates between benign nevi and 
malignant pigmented skin lesions such as melanomas. Given the location of the lesion, it is reasonable for 
patient to be checked for malignancy prior to committing to a wide local excision of the nose. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services (DermTech melanoma test) performed on August 2, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography, abdomen and pelvis; without 
contrast material (74176) provided May 28, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the diagnoses codes should not be reported together which is based on the Excludes1 Notes 
instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the file shows that code 
74176 was denied because the diagnosis codes associated to K52.9 (Noninfective gastroenteritis and colitis, 
unspecified) and R19.7 (Diarrhea, unspecified) should not be reported together. The billed service has been 
denied because it was reported with one or more diagnosis code pairs that are subject to an Excludes1 note, per 
the 2023 ICD-10-CM Tabular. Therefore, we decided that the Plan does not have to pay for the computed 
tomography, abdomen and pelvis; without contrast material (74176) provided May 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glycopyrrolate. 
 
You asked the Plan to pre-approve Glycopyrrolate. 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 Glycopyrrolate.  Benefits for Glycopyrrolate 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
accessories (E0670). 
 
You asked the Plan to pre-approve a pneumatic compression device and related accessories. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for the PCD at issue have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Because the base PCD is not covered, the requested related accessories are not eligible for 
reimbursement. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression 
device (E0652) and related accessories (E0670).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission provided from June 29, 2022, to  
July 1, 2022.  
 
You asked the Plan to pay for the inpatient admission. You say that the inpatient care was medically necessary 
and should be paid separately from this first admission. The Plan denied your request. The Plan says the patient with pneumonia was discharged to home. Improved coordination between the inpatient and outpatient health 
care teams including pre-arranged post hospital follow up appointments may have prevented the readmission 
for pneumonia. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 inpatient admission. Our reviewer says 
that the readmission was medically necessary. Our physician reviewer found the patient was tachycardic and a 
marked leukocytosis that responded with antibiotics. It is not clear the result of the readmission from a 
premature discharge or just misdiagnosis or evolution of her disease course over time. Given this uncertainty, 
we do not believe the readmission was caused by an appropriate discharge.  
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for an inpatient admission provided from June 29, 2022, to July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from August 10, 2021, to August 
14, 2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation of reconsideration. The Plan denied your request. The Plan says that the 
DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the enrollee presented with fever, weakness, shaking, dizziness and confusion. The enrollee was found to have 
a fever, leukocytosis and elevated lactate. A clear source of infection was not initially noted, but suspected to 
be chronic lower extremity wounds. The enrollee was hospitalized and started on antibiotics. Blood cultures 
were positive, and the antibiotic course was extended. The enrollee exhibited both mild hypo- and hypertension 
and both mild brady- and tachycardia. There is insufficient evidence to say the enrollee did not have sepsis. As 
such, the health plan has failed to support its denial.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services rendered from August 10, 2021, to August 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump billed with code 
E0217 for February 24, 2023, to March 16, 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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a water circulating heat pad with pump is denied 
as not medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is a water circulating heat pad with pump billed 
with code E0217. This item is denied by Medicare as not reasonable and necessary. Therefore, we decided that 
the Plan does not have to pay for the water circulating heat pad with pump billed with code E0217 for February 
24, 2023, to March 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for pembrolizumab and paclitaxel for the enrollee.

You asked the Plan to provide coverage for this request. You say that at the time of the appeal this drug was medically necessary. The Plan denied your request. The Plan says the 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 Pembrolizumab. The medical records show the enrollee was a then 80-year-old man with a diagnosis of non-small cell cancer of right lung T2bNxM0 stage IIA and bronchogenic carcinoma. Taxol/Carboplatin with concurrent radiation therapy was given from November 2, 2022, through December 21, 2022. Durvalumab was initiated on January 19, 2023. The enrollee then developed worsening shortness of breath, with an endobronchial ultrasound showing narrowing of the right mainstem bronchus, bronchus intermedius, and lobar RUL bronchus. Paclitaxel was initiated on June 13, 2023. On June 20, 2023, the enrollee was doing fairly well clinically. The treatment plan was continued with the current treatment. Caris testing reported on April 18, 2023 was positive for PD-L1; Keytruda was recommended.

The Plan is correct in this case. Pembrolizumab is FDA-approved as a single agent for the first-line treatment of patients with NSCLC expressing PD-L1 [Tumor Proportion Score (TPS) =1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is Stage III where patients are not candidates for surgical resection or definitive chemoradiation, or metastatic. The documentation does not support that the enrollee in this case is not a candidate for surgical resection or definitive chemoradiation or has metastatic disease. 

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 request have not been met. Therefore, we decided that the Plan does not have to provide coverage for pembrolizumab and paclitaxel for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related supplies. 
 
You asked the Plan to pre-approve the requested services. You say that the lymphedema has not responded to 
conservative treatments. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee has failed a four-week trial 
of a basic pump. Based on this information, we decided that Medicare rules for coverage of the requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702)  
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee was referred by their doctor 
for myoelectric restoration using the MyoPro Motion G. The Plan denied your request. The Plan says this item 
is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with 
stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy stretch strap (E1399). 
 
You asked the Plan to pre-approve the physical therapy stretch strap. You say that you have hip and iliotibial 
band (ITB) issues and this DME is what you need to do your exercises. The Plan denied your request. The Plan 
says this item is not considered a covered DME item. 
 
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 the physical therapy stretch strap (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine. 
 
You asked the Plan to pre-approve the medication. You say that this 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 Prochlorperazine.   
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve the medication. You say that this 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 Wegovy.   
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 21, 2023, to 
February 5, 2023, billed with evaluation and management codes 99232 and 99233. 
 
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 documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 the practitioner services provided have 
been met. Specifically, no medical records have been provided for the dates of service in question. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on January 21, 2023, to 
February 5, 2023, billed with evaluation and management codes 99232 and 99233.