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

We decided that the Plan does not have to provide coverage for a Tempus xF liquid biopsy for the enrollee.

You asked the Plan to provide coverage for a Tempus xF liquid biopsy. The Plan denied your request. The Plan
says this testing is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria. The Plan notes that Tempus xF does not have either
Food and Drug Administration (FDA) approval, or clearance as a companion in vitro diagnostic test, therefore
this test is not covered.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of testing. The Tempus xF Panel genetic testing in this case did not meet the required coverage
criteria for genetic testing.

This testing does not have FDA approval or clearance, and an FDA-approved or FDA-cleared indication for
use in this enrollee's condition. Therefore, we decided that the Plan does not have to provide coverage for a
Tempus xF liquid biopsy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytogenetic testing rendered on August 1, 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 testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cytogenetic testing is covered for specific 
diagnoses only. We looked at the file and Medicare rules. The file shows that the testing at issue was not provided for a covered 
diagnosis. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the cytogenetic testing rendered on 
August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6222 provided on September 13, 2023. 
 
You asked the Plan to pay for procedure code A6222. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 code A6222 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have 
to pay for procedure code A6222 provided on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) supplies for 
maintenance of non-insulin drug infusion catheter, per week (list drugs separately) (A4221) and infusion 
supplies not used with external infusion pump, per cassette or bag (list drugs separately) (A4223) provided July 
26, 2023, to August 14, 2023. 
 
You asked the Plan to pay for the disposable drug delivery system and supplies. You say that your department 
require reimbursement for the unpaid charges that are indicated on the claims that include the necessary 
supplies and service charges applicable to the medication being administered to the enrollee. The Plan denied 
your request. The Plan says this service is not covered by Medicare 
 
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 disposable drug delivery system and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for the disposable drug delivery system (A4305) supplies for maintenance of non-
insulin drug infusion catheter, per week (list drugs separately) (A4221) and infusion supplies not used with 
external infusion pump, per cassette or bag (list drugs separately) (A4223) provided July 26, 2023, to August 
14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation and chiropractic manipulative 
treatment provided on July 19, 2023. 
 You asked the Plan to pay for the electrical stimulation and chiropractic manipulative treatment. You say that 
these services should be covered. 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 $70 
copayment for chiropractic services.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
The electrical stimulation at issue is not manual manipulation of the spine. Therefore, we decided that the Plan 
does not have to pay for the electrical stimulation provided by a chiropractor on July 19, 2023. 
 
You have been asked to pay $38.37, which is less than the standard $70 copayment for the chiropractic 
manipulative treatment. This item/service falls within the chiropractic 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 pay for the chiropractic manipulative treatment provided on July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 15, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one code. 
 
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 the lab panel provided on June 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan rendered on 
May 16, 2023. 
 
You asked the Plan to pre-approve the scan. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when 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 pre-approve the scan. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
reason for the exam was weigh loss and ascites. The ICD-10 code for the exam was listed as peritoneal carcinoma, and as such has been denied as an unacceptable code. The enrollee has no known diagnosis of 
malignancy hence the ICD 10 code of peritoneal carcinoma is not allowed for the indication of the exam. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan rendered on May 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of 4 
additional PT visits. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that based on the medical records provided there is no documentation 
that the 4 denied PT visits meet Medicare criteria for coverage. Records do not support that the complexity of 
your condition are such that the skills of a professional therapist are required to achieve further improvement in 
your symptoms or functional status. You do not have significant functional deficits with regards to performing 
your daily activities and your progress has largely plateaued. You continue to have low back pain, but 
additional progress can be accomplished in the context of a home exercise program and does not require the 
services of a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary and 
therefore cannot be covered.  

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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics (E2311, E2313, E2377) are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the provided records indicate that the enrollee has 
adequate strength to manage standard power drives. Therefore, the reviewer found that the requested upgraded 
electronics are 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee from
September 23, 2022, to September 27, 2022.

You asked the Plan to pay this claim as billed. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the
Plans decision for insufficient explanation of their denial. The Plan requested a reopen and provided additional
information. The Plan noted that this claim was denied because this service was billed with an inappropriate
Discharge Status Code. The discharge status code identifies if the enrollee is being discharged at the end of
their facility stay to another facility or to their home. The provider billed code "09" indicating the enrollee was
admitted as an inpatient. However, the provide should have billed code "01" as the enrollee was discharged
home and not to another facility.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the claim was billed with an inappropriate discharge status code.
Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does
not have to pay for inpatient mental health services provided to the enrollee from September 23,
2022, to September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro powered upper extremity range of motion 
assist device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's brachial plexus condition or in widespread use for this patient's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this patient.  There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myopro powered upper extremity range of motion assist device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure would help relieve the 
enrollee's pain. The Plan denied your request. The Plan says this procedure is considered experimental.  
 
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 an Intracept procedure. 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 magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis. The cause of pain is also unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 11, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 September 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you still require extensive hands-on assistance from 
the nursing and therapy staff at the hospital to get out of bed. You say that your doctor wants you to continue 
with medical management. The Plan denied your request. The Plan says you do not meet the criteria 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 you are medically stable, and no acute rehabilitation skilled nursing needs were 
identified or documented. You do not need specialized intensive therapies consisting of at least 3 hours of 
therapy per day, at least 5 days per week. Your rehabilitation needs can be provided in an alternate and low 
intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for date of service August 4, 
2023. 
 
You asked the Plan to pay for procedure code P9603. You say that this service was billed correctly and should 
be paid. The Plan denied your request. The Plan says this code was not billed in accordance with Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that Medicare pays a travel 
allowance when a specimen collection fee is paid. In this case, the CPT Code Manual definition of code P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, this code for travel 
allowance was not billed with a related laboratory specimen collection service. Based on this information, we 
decided that Medicare rules for coverage of procedure code P9603 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code P9603 billed for date of service August 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy for implantation of neurostimulator 
electrodes. 
 
You asked the Plan to pre-approve a laminectomy. You say that the enrollee has severe neck pain and has tried 
conservative measures. The Plan denied your request. The Plan says the medical criteria for this procedure 
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 a laminectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical criteria for a neuro spinal cord stimulator have not been met. A psychiatric 
evaluation was not provided, 
 
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 laminectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a laminectomy for implantation of neurostimulator electrodes.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22595 rendered on April 7, 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 procedure code 22595 is not supported in the 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 22595 is "Arthrodesis, posterior technique, atlas-axis 
(C1-C2)." 
 
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 enrollee was being treated for 
cord compression and spinal stenosis of the cervical region. The underwent a C2-T2 posterior decompression and fusion on 4/7/23. However, the operative report does not support that any procedure was performed at the 
C1-2 level. Therefore, the documentation does not support that CPT 22595: arthrodesis, posterior technique, 
atlas-axis (C1-C2) was rendered in this case. 
 
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 22595 rendered on April 7, 2023.