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

 
We decided that the Plan does not have to pre-approve fermuoxytol. 
 You asked the Plan to pre-approve fermuoxytol. The Plan denied your request. The Plan says that the 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 fermuoxytol. Our reviewer says that 
fermuoxytol is not medically necessary. Our physician reviewer found that the enrollee has an iron deficiency, 
and the requested medication is a new start. However, there is no indication that the enrollee has tried and 
failed the Plan's preferred step one alternative. Also, there is no indication that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. Therefore, 
the elements of the coverage criteria 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 fermuoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fermuoxytol.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 6, 2022, billed 
with codes 81314, 81162, 81209, 81218, 81406, and 81437. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
September 6, 2022, billed with codes 81314, 81162, 81209, 81218, 81406, and 81437.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0380) for tooth #14 provided on April 24, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you could not find an in-network provider and 
the x-rays were necessary for the root canal. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because the cone beam is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0380) for tooth #14 provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95941 and 95955 billed for date of service 
September 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the monitoring helps avoid iatrogenic injuries. 
The Plan denied your request. The Plan says the services are not payable. 
 
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 95941 has a 
Status Indicator of I on the Physician Fee Schedule. This means that procedure code 95941 is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the billed 
services 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 pay for procedure code 
95955. Our physician review says that the enrollee reported no history of hypertension, diabetes, seizures, 
stroke or metal implants. The provided medical records and review of the current peer-reviewed medical 
literature do not document that use of the EEG during lumbar spine surgery (in this case, L3-S1 posterior 
fusion with decompression) has been shown in controlled studies to result in long term health benefits in 
patients with lumbar stenosis undergoing surgery. Therefore, the service was 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 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 95941 and 95955 billed for date of service September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on February 19, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the supplies. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says this service was 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 supplies provided on February 19, 2023, by an 
out-of-network OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor (implantable 
loop recorder [ILR]). 
 
You asked the Plan to pre-approve the ILR device. You say that this can be approved for cryptogenic stroke as 
well as management of atrial fibrillation. The Plan denied your request. The Plan says the documentation does 
not show any recent episode of syncope. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found the documentation does not 
support any history of recent cryptogenic stroke or recurrent, unexplainable syncope as required by the 
guidelines. Therefore, the reviewer found that the requested ILR device 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 the ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a subcutaneous cardiac rhythm monitor (implantable loop recorder [ILR]).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine Therapeutic Guidance testing provided on March 
13, 2023. 
 
You asked the Plan to pay for the Urine Therapeutic Guidance testing . You say that this test should be covered 
by the Plan. The Plan denied your request. The Plan says this test is not FDA approved and has not registered 
with MolDx as having completed a technical assessment. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing must have FDA approval or must 
register with MolDX with an approved TA. 
 
We looked at the file and Medicare rules. We find that the Urine Therapeutic Guidance test has not been 
approved for coverage based on information in the DEX Diagnostic Exchange Based on this information, we 
decided that Medicare rules for coverage of the Urine Therapeutic Guidance testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Urine Therapeutic Guidance testing provided 
on March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary 
and other devices will not meet the patient's needs. The Plan denied your request. The Plan says the patient's 
needs could be met with a bilevel positive airway pressure (BiPAP) device with average volume-assured 
pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease.  The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of 
such a device has not been documented.  The Plan has indicated coverage for such a device is available upon 
request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the care provided at the IRF and 
you would like reconsideration of this denial. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for admission to an IRF. 
 
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. There is no 
support in the documentation that the enrollee requires the intensive medical care and the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022, to August 19, 
2022. 
 
You asked the Plan to pay for an office visit. You say that the services were 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 an office visit provided 
on June 14, 2022, to August 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on December 8, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says insufficient medical records were submitted to support the services billed. Maximus overturned the Plans denial for insufficient records in the file. The Plan requested a reopen and stated that several attempts were made to obtain records from the provider however no response was provided.
The Plan is correct in this case. 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 these services have been met.
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty. 
 
You asked the Plan to pre-approve the kyphoplasty. You say that you are in pain and cannot move. You say 
that without this surgery you will not be able to perform daily tasks The Plan denied your request. The Plan 
says the kyphoplasty is not medically necessary. The Plan says there is no documentation of bone marrow 
edema. 
 
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 the kyphoplasty. Our reviewer says that 
the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MRI shows a sacral insufficiency fracture of unknown age and cement augmentation of the 
sacrum is experimental. There is no edema in any other vertebral body to justify kyphoplasty at any other 
vertebral level. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291-59 billed for date of service February 
22, 2023. 
 
You asked the Plan to pay for the billed services. You say that emergency room visits and inpatients visits are 
billable for the same date of service. The Plan denied your request. The Plan says the modifier is not 
appropriate. 
 
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 looked at the file and the rules. CPT code 99291 was not billed with a modifier suitable for separate 
payment. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291-59 billed for 
date of service February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 You asked the Plan to pre-approve the office visit to be provided by an out-of-network provider. You say that 
you unable to walk more than five minutes with your condition that has lasted for two months and you are 
experiencing pain on your left foot. The Plan denied your request. The Plan says you must receive your care 
from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. 
The Medicare Advantage program organizes your care within a single medical group of providers. Exceptions 
are allowed when care cannot be provided by the primary care physician's medical group 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The contract also 
says when you choose your PCP, you are also choosing the affiliated medical group. This means that your PCP 
will be referring you to specialists and services that are also affiliated with his or her medical group. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
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 needs to be medically and 
functionally assessed to determine whether an LTACH level of care would be beneficial. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. 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. The requested service cannot be recommended as 
the elements of the coverage rules are not satisfied. 
 
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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs therapy and is not ready to return 
home. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for an 
SNF admission.  
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 23, 2023, billed 
with evaluation and management (EM) code 99238. 
 
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 code. 
 
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 99238 is hospital discharge day management; 30 minutes 
or less. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that this claim is not coded to the highest 
level of specificity. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 23, 2023, billed with evaluation 
and management (EM) code 99238.