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

 
We decided that the Plan does not have to pay for the lab services provided on February 2, 2023. 
 
You asked the Plan to pay for the lab services. You say that this is an important test for transplant surgeons to 
rely on. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from January 5, 2023, to February 3, 2023.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, there is not a valid NOA submitted with records provided. 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 home health services provided to the enrollee from January 5, 2023, to February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the home ventilator provided on February 6, 2023. 
 
You asked the Plan to pay for the ventilator. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a ventilator is covered for the indications established 
in the applicable LCD. 
 
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 ventilator. Our reviewer says that the 
requested home ventilator is medically reasonable and necessary. Our physician reviewer found that the 
enrollee has severe chronic obstructive pulmonary disease (COPD) with chronic respiratory failure and has 
been utilizing a trilogy ventilator with average volume-assured pressure support-automated expiratory positive 
airway pressure (AVAPS-AE) since 2020.  If the enrollee were to be denied it would be considered a reduction 
or withdrawal of therapy as he has been treated for several years and the documentation does not show any 
worsening respiratory status or hospitalizations. Withdrawal of this therapy would not be best practice. The 
enrollee has been treated with trilogy for years and removal of this treatment modality can be detrimental to 
patient, and hence, should be continued.  

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 ventilator have been met. Therefore, we decided that the Plan has to pay for 
the home ventilator provided on February 6, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an OsteoCel allograft (20930). 
 
You asked the Plan to pre-approve an OsteoCel allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the OsteoCel Allograft in the setting 
of a lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 OsteoCel allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 OsteoCel allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an OsteoCel allograft (20930).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary, and 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from December 5, 2022, to January 3, 2023.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The records show while an NOA was submitted within 5 days of the start of this billing period, it was not submitted within 30 days of the start of care which is the limit for an automatic denial. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from December 5, 2022, to January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device at L4-
L5. 
 
You asked the Plan to pre-approve a Vertiflex Superion interspinous spacer device. You say that the enrollee 
has suffered from his condition for too long. The Plan denied your request. The Plan says there is a lack of 
evidence to support interspinous spacer devices as safe and effective as the gold standard of surgical 
decompression. 
 
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 Vertiflex Superion interspinous 
spacer device. 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 discussion of scoliosis of the lumbar spine, with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has 
demonstrated the lack of significant osteoporosis in the enrollee. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Vertiflex Superion interspinous spacer at L4-5, in this case, 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 a Vertiflex Superion interspinous spacer device] have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device at L4-
L5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (G6002, 77387, 77525). 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found for this enrollee, there are no records showing that standard dosimetric constraints 
could not be met and it is not plausible that this would be the case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (G6002, 77387, 77525).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 22, 2022, to 
August 20, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 22, 2022. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered from July 22, 
2022, to August 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 billed for date of 
service March 28, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for diabetes problems. The 
Plan denied your request. The Plan says the billed code is not supported. 
 
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 file shows that the enrollee received outpatient intravenous insulin therapy. We find that CPT codes 96365, 
96366, and 96521 are not supported in the medical record. Specifically, there are more accurate codes that 
describe the services provided. The records do not substantiate that subsequent refilling of the pump was 
provided.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 
billed for date of service March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Negative Pressure Wound Therapy (NPWT) Pumps. 
 
You asked the Plan to pre-approve NPWT pump. You say that it is medically necessary. The Plan denied your 
request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 4 months (including the time NPWT was applied in 
an inpatient setting prior to discharge to the home) have elapsed using a NPWT pump in the treatment of the 
most recent wound. 
 
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 NPWT pump. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found you had already completed the maximum 
allowed use of wound VAC therapy (4 months). Therefore, the criteria are not met for ongoing use of this 
device based on the Local Coverage Determination (LCD). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NPWT pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Negative Pressure Wound Therapy (NPWT) Pumps.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MAKOplasty robotic/computer assisted surgical 
systems (20985, S2900). 
 
You asked the Plan to pre-approve robotic/computer assisted surgical systems. You say that these services have 
been approved in the past. The Plan denied your request. The Plan says the knee arthroplasty has been 
approved; however, the use of computer and robotic assisted surgical systems are not considered reasonable 
and 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 pay for robotic/computer assisted surgical systems. 
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 large volume of long term/high quality clinical studies that confirm clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-
assisted surgery over standard surgical approaches in total knee arthroplasty. No compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested MAKOplasty robotic/computer-assisted surgical systems 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 robotic/computer assisted surgical systems have not been met. Therefore, we 
decided that the Plan does not have to pre-approve MAKOplasty robotic/computer assisted surgical systems 
(20985, S2900).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on February 8, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin removal and skin substitute (TheraSkin). 
 
You asked the Plan to pre-approve TheraSkin. You say that the procedure would improve the enrollee's 
probability of a favorable outcome. The Plan denied your request. The Plan says that using TheraSkin with an 
active infection is contraindicated. 
 
The Plan follows Medicare rules. Medicare rules say that skin substitutes to ulcers or wounds may be covered 
under certain circumstances. 
 
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 TheraSkin. Our reviewer says that the 
requested TheraSkin skin substitute application for this enrollee is not medically reasonable or necessary. Our 
physician reviewer found that the medical documentation advises that this enrollee continues to suffer with 
osteomyelitis of the foot and involved skin infection and is currently on antibiotics. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TheraSkin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin removal and skin substitute (TheraSkin).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging service (93971) provided on February 15, 2023. 
 
You asked the Plan to pay for the imaging service. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says the diagnosis codes reported on this claim were not 
reported in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that some diagnosis codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the 
medical record, assign the code for the unspecified side.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging service have not been met. Specifically, diagnosis codes R22.41 (localized swelling, 
mass and lump, right lower limb) and R22.42 (localized swelling, mass and lump, left lower limb) were both 
reported, indicating that this condition is bilateral. However, code R22.43 (localized swelling, mass and lump, 
lower limb, bilateral) exists but was not used. If a condition is bilateral and a bilateral code exists, the bilateral 
code should be used. Therefore, we decided that the Plan does not have to pay for the imaging service (93971) 
provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided March 6, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable this instance. The Plan denied your request. The Plan says the requested 
test is not reasonable and necessary because Tempus xF has not had FDA approval. 
 
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. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this patients cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided March 6, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rinvoq. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rinvoq.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable to discharge to 
LTACH level of care, however the enrollee is not clinically appropriate for a lower level of care. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary.  
 
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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan.  
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 LTACH services.