Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the services are 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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the health plan. The 
records do not demonstrate that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. The requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The 
documentation does not support that the enrollee requires ongoing formal therapy. The enrollee has had pain 
complaints which have been a barrier to consistent therapy participation. The enrollee has been instructed in a 
home exercise program.  They have staff assist in the long term care facility. The requested additional therapy 
sessions are 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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 30 additional physical therapy (PT) visits.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. You say that the preferred medications are not an option at your 
office, as you do not carry them. You also say that since you do not carry either of the preferred medications, 
you feel that this would fall into the category of not an option, therefore, you would like the denial of Eylea to 
be reconsidered. The Plan denied your request. The Plan says the requested service does not meet medical 
necessity criteria. 
 
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 Eylea. Our reviewer says that the 
enrollee does not meet the coverage criteria for Eylea. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 13, 2023. 
 
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 payment for the billed services is included in 
payment for the inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that non-diagnostic outpatient hospital services 
provided within 3 days of an inpatient admission are not separately payable unless the services are unrelated to 
the admission and condition code 51 is reported. 
 
We looked at 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. The billed services were provided within 3 
days prior to the inpatient admission and the claim was not reported with condition code 51. As such, these 
services are not separately payable. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on February 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this drug is necessary for the enrollee's treatment. The 
Plan denied your request. The Plan says the accepted use of this drug for your condition requires that the 
enrollee's condition is nonmetastatic. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pre-approve Prolia. Our reviewer says that the 
requested use of Prolia is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's specific clinical situation. Therefore, the reviewer found that the requested use of Prolia 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit provided to the enrollee on September 27, 2022.
You asked the Plan to pay for the TENS unit. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you have been renting the TENS unit every month to this member since June 27, 2022.
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 TENS unit have been met. Current medical records have not been provided to confirm the TENS unit was still necessary for the enrollee's care. Therefore, we decided that the Plan does not have to pay for the TENS unit provided to the enrollee on September 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87481 (x2) billed for date of service January 27, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says that this code is not supported in the medical 
record, as these two services would be better reported with code 87801. 
 
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 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. 
 
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 procedure code 87481. Our reviewer says that code 87481 is 
supported for two units. Our reviewer found there are two line items on the lab results showing that two 
different candida species were tested. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87481 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87481 (x2) billed for date of service January 27, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit provided to the enrollee on September 18, 2022.
You asked the Plan to pay for the TENS unit. You say that this should be paid for. The Plan denied your request. The Plan says that the reconsideration decision to uphold the claim comply with all Medicare claim payment, billing and coverage policies.
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 TENS unit have been met. Current medical records have not been provided to confirm the TENS unit was still necessary for the enrollee's care. Therefore, we decided that the Plan does not have to pay for the TENS unit provided to the enrollee on September 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 additional intraoral x-rays (D0230) provided on November 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for x-rays 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 Plan's 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 November 21, 2022. 
Therefore, we decided that the Plan does not have to pay for 2 additional intraoral x-rays (D0230) provided on 
November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth per quadrant for the lower right quadrant (D4341) and periodontal scaling and root planing-one to three teeth per quadrant for the lower left quadrant (D4342).
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided claim documentation.
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, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service June 16, 2022. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth per quadrant for the lower right quadrant (D4341) and periodontal scaling and root planing-one to three teeth per quadrant for the lower left quadrant (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on March 9, 
2023. 
  
You asked the Plan to pay for the dental service. You say that you were given the name to a provider and that is 
where you went so the claim should not be denied. The Plan denied your request. The Plan says the denial of 
payment authorization for this service is correct, because the full mouth debridement 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 the full 
mouth debridement (D4355) provided on March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occupied transit (K0108). 
 
You asked the Plan to pre-approve an occupied transit. You say that the item in question is not an integral part 
of the base, thus a split decision should be possible. The Plan denied your request. The Plan says this does not 
serve a medical need and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also state that for equipment to be covered, it must be appropriate and needed for 
use inside the home.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The item at issue in 
this appeal is also for use outside of the home. Although this item may be helpful, neither Medicare nor the 
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve an occupied transit (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service November 17, 2022.
You asked the Plan to pay for code J3490. You say that the drug was a necessary part of the enrollee's treatment. The Plan denied your request. The Plan says that the code is included in the global surgery period for procedure 20610. Maximus overturned the Plans denial stating the code was valid. The Plan requested a reopen and demonstrated that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 20610 that was billed on the same claim.
Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service. Per the above Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service.
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, payment for code J3490 in this case was included in the payment for the administration and infusion services. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit provided to the enrollee on September 28,
2022.
You asked the Plan to pay for the TENS unit. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says that there is no indication in the records that the
members physician has documented that there has been significant benefit from the continuous use of the unit.
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 TENS unit have been met. Current medical records have not been provided to confirm the TENS unit was still necessary for the enrollee's care. Therefore, we decided that the Plan does not have to pay for the TENS unit provided to the enrollee on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit supplies provided to the enrollee on September 27, 2022.
You asked the Plan to pay for the TENS unit supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says that since the provider is renting the TENS Unit to the member the provider should not bill for supplies. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The provider is billing the units in excess of the Medicare allowed amount. Therefore, this claim was denied correctly.
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 provider is billing for supplies separately for rented equipment, which is not allowed. The provider is also billing in excess of the normal units allowed by the billing guidelines. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the TENS unit supplies provided to the enrollee on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unspecified endodontic procedure, by report 
(D3999). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit.  
  
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
unspecified endodontic procedure, by report (D3999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit supplies (A4595) provided to the enrollee on September 5, 2022.
You asked the Plan to pay for the TENS unit supplies. You say that this claim was billed correctly. The Plan denied your request. The Plan says that the provider did not submit any evidence that they have been contacting the member before shipping additional supplies. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and indicated this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. Therefore, this claim was denied correctly.
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 provider is billing for supplies separately for rented equipment, which is not allowed. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the TENS unit supplies (A4595) provided to the enrollee on September 5, 2022.