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

 
We decided that the Plan does not have to pay for the testing provided on September 24, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on September 24, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided during a hospital stay on 
February 21, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the hospital gave you the drugs to take and 
you should not be responsible for the charge. The Plan denied your request. The Plan says self-administered 
drugs are 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. There is no documentation in the case record to support that the self-administered drugs at 
issue here are among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does 
not have to pay for self-administered drugs provided during a hospital stay on February 21, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sedation services (99152). 
 
You asked the Plan to pre-approve the sedation services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 the sedation services. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has received prior injections without evidence of required sedation. The 
documentation does not show that sedation is medically necessary to perform the currently planned injection. 
 
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 sedation services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sedation services (99152).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 enrollee does not have complex or intensive rehabilitation needs. Post-acute 
deconditioned state can be addressed at a variety of levels of care and does not require intensive rehabilitation 
or frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 3, 2022, to 
September 11, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. 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 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 secondary diagnosis code J96.01, described as 
Acute respiratory failure with hypoxia. 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 documentation does not support 
the billed code. Our physician reviewer found that the enrollee is a 69-year-old female with a past medical 
history including atrial fibrillation, chronic bronchitis, Parkinson's disease and diabetes mellitus who was 
admitted to the hospital with shortness of breath with volume overload. She was treated in the emergency 
department with diuretic medication. She stabilized medically and required 2-3L of supplemental low-flow 
oxygen via nasal cannula. She was not treated with Bilevel positive airway pressure or other forms of 
mechanical ventilation. The documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 3, 2022, to September 11, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve follow-up care with an out-of-network (OON) tertiary 
care provider.  
 
You asked the Plan to pre-approve follow-up care with an OON tertiary care provider. You say that you are in 
the middle of cancer treatment. The Plan denied your request. The Plan says a network provider can provide 
the medical care required.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 follow-up care with an OON tertiary 
care provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found there is nothing unique about the enrollee's condition that would make it medically necessary 
for her to continue care with the OON provider location being requested. The Plan has offered coverage at an 
in-network tertiary care facility location that has the qualifications and expertise necessary to meet the current 
medical Standards of Care required for treatment of the enrollee's condition. The enrollee's systemic treatment 
can be continued at the in-network tertiary care facility location that the Plan has referred them to.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of follow-up care with an OON tertiary care provider location have not been met. 
Therefore, we decided that the Plan does not have to pre-approve follow-up care with an out-of-network 
(OON) tertiary care provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine testing provided to the enrollee on November 23, 2022, and billed under codes 87150-59, 87798-59, 87487-59, 87801-59, 87640-59, and 87653-59. 

You asked the Plan to pay for this claim as billed. The Plan denied your request. The Plan says these codes cannot be billed separately on this type of testing and/or specimen. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan notes that the enrollee was diagnosed with a UTI. A test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components even if the test reports multiple individual pathogens and/or targets. The Plan paid code 87801 only, as that code was appropriately billed for the service provided. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim was billed inappropriately based on the Medicare rules for this type of testing. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to pay for urine testing provided to the enrollee on November 23, 2022, and billed under codes 87150-59, 87798-59, 87487-59, 87801-59, 87640-59, and 87653-59.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 Intracept. 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 and no facet 
degenerative joint disorder or foraminal stenosis. The cause of the enrollee's back pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio nerve stimulator device. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says neither Medicare nor the plan 
covers this request. Medical studies have not proven this service/item is helpful for the treatment of the 
enrollee's health problem. 
 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 Cala Trio nerve stimulator device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of essential tremor. Per documentation, the 
tremor has gotten worse, and the enrollee is having symptoms despite taking propranolol and primidone. The 
tremor interferes with most activities. Per NCD 160.2, it states that electric nerve stimulation employed to treat 
motor function disorder cannot be considered reasonable and 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 a Cala Trio nerve stimulator device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 very heavy-duty power wheelchair (K0860), 
cushioned headrest (E0955), general use wheelchair seat cushion (E2601), power seating system, tilt only 
(E1002), group 24 sealed lead acid battery (E2363), retractable or removable mounting hardware for joystick 
(E1028 x2), and electronic connection between wheelchair controller and one power seating system motor 
(E2310). 
 
You asked the Plan to pre-approve a group 3 very heavy-duty power wheelchair and additional items and 
accessories. You say that the enrollee's diagnosis does allow for the group 3 type chair. The Plan denied your 
request. The Plan says the enrollee does not have medical need for single power options included with group 3 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in MRADLs, the patients condition 
can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the 
requested PMD. 
 
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 group 3 very heavy duty power 
wheelchair and additional items and accessories. Our reviewer says that this request is not medically reasonable 
and necessary for the enrollee. Our physician reviewer found a power drive option is not necessary as the 
enrollee does not have skin breakdown, high risk for skin breakdown, does not use catheter, or have spasticity. 
Our reviewer also found that the enrollee does not require alternative means of power drive control. 
 
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 group 3 very heavy duty power wheelchair and additional items and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 very 
heavy-duty power wheelchair (K0860), cushioned headrest (E0955), general use wheelchair seat cushion 
(E2601), power seating system, tilt only (E1002), group 24 sealed lead acid battery (E2363), retractable or 
removable mounting hardware for joystick (E1028 x2), and electronic connection between wheelchair 
controller and one power seating system motor (E2310).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.

You asked the Plan to pre-approve Eylea. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy 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 documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has neovascular (wet) age-related macular degeneration. The documentation does not support that the enrollee has tried and failed the ophthalmic formulation of bevacizumab. The documentation does not support that the ophthalmic formulation of bevacizumab would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug.

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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 15, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on January 15, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the basivertebral nerve ablation (BVN) (intracept 
intraosseous nerve ablation system) for L3  S1 (64628 and 64629). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 services. 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 
degenerative joint disease (DJD) or foraminal stenosis. The cause of back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the basivertebral nerve ablation (BVN) (intracept intraosseous nerve ablation system) for 
L3  S1 (64628 and 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator (E1390) purchased March 2, 2023.

You asked the Plan to reimburse you for the oxygen equipment. You say that you were not told that the Plan does not reimburse for oxygen equipment. You were told that you were entitled to reimbursement of 80%. The Plan denied your request. The Plan says that purchased oxygen equipment is not covered.

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 the Plan will cover for the rental of oxygen equipment.

You have asked for reimbursement for the purchased portable oxygen concentrator. Medicare will only consider an oxygen claim for payment when the equipment is rented. This item/service falls within the Durable medical equipment (DME) and related supplies 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 reimburse you for the portable oxygen concentrator (E1390) purchased March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service November 
15, 2022.  
 
You asked the Plan to pay for procedure code 88341. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the catheter placement in artery and lower extremity 
revascularization (36245, 37232, 37221, 37226). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 services. Our physician reviewer 
found while the enrollee has a history of peripheral vascular disease, the enrollee is without symptoms; 
moreover, the non-invasive studies provided are not consistent with severe disease. In summary, there is 
insufficient documentation to support the medical necessity for lower extremity angiography and 
revascularization in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the catheter placement in artery and lower extremity revascularization (36245, 37232, 
37221, 37226).