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

 
We decided that the Plan does not have to pre-approve treatment with Aranesp (J0881). 
 You asked the Plan to pre-approve Aranesp. You say that Aranesp is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Aranesp have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that 
treatment with Aranesp is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of Retacrit or Procrit before they will approve the requested drug. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. 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 alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Aranesp (J0881).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81546) provided on October 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is covered and should be paid. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81546) provided on October 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 13, 2022.
You asked the Plan to pay for procedure code 71045. You say that these services were medically necessary. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 36558.
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, we have confirmed that code 71045 is a column II code to column I code 36558. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from November 4, 2021, to November 7, 2021, and billed under a specific Diagnosis Related Group (DRG).
You asked the Plan to pay for the inpatient hospital services. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans denial for no medical records in the case file. The Plan requested a reopen and provided the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is the plan's decision to remove secondary diagnosis code N17.9 (Acute renal failure, unspecified). The discharge summary dated November 7, 2021, states "A 60-year-old male with past medical history of multiple medica1 problems, on and off hypotension. The patient presented status post syncopal episode and passed out. The patient's family noticed 1oss of consciousness. The patient was diagnosed with CT scan and traumatic nondisplaced lateral margin of the tempora1 bone mandibu1ar fracture. The patient was seen by ENT and medica1y managed with right TMJ dysfunction. The patient, once tolerating diet and pain controlled, the patient was discharged." The emergency department note dated November 4, 2021, states "Vital signs notable for tachycardia. BUN = 35, Creatinine = 2.66. The Clinical Impression included "Moderate acute renal failure." On November 5, 2021 the BUN was 28 and Creatinine was 1.67. The history, physical and assessment plan did not include a diagnosis of Acute renal failure. The consult from cardiology states "He is found to have renal failure likely from dehydration." The Plan is correct in this case. The clinical documentation does not sufficiently support a secondary diagnosis code of N17.9 (Acute renal failure, unspecified). 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 care provided to the enrollee from November 4, 2021, to November 7, 2021, and billed under a specific Diagnosis Related Group (DRG).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from October 1, 2022, to October 2, 2022, and billed under code 99291.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan submitted the claims showing the billing error. The Plan noted code 99291was not billed in accordance with Medicare National Correct Coding Initiative Policy - Medically Unlikely Edits (MUE). Code 99291 has a Medically Unlikely Edit (MUE) value of 1 unit; however, 2 units were billed on the claim.
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, this claim could not be paid as billed due to the MUE edit for code 99291.
Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from October 1, 2022, to October 2, 2022, and billed under code 99291.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the drainage bag (A4357) provided to the enrollee on March 11, 2022.
You asked the Plan to pay for the drainage bag. You say that you would like payment made for this service. The Plan denied your request. The Plan says that code A4357 is a column II code and payment is bundled in column I code A4314. Maximus overturned the Plan's denial. The Plan requested a reopening stating that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that payment for items listed in Column II are included in the payment for the Column I code.
In the following table, when providing the items listed in Column II, the Column I code must be used instead of billing separate Column II codes when the items are provided at the same time. We looked at the file and Medicare rules. The file indicates that code A4314 was provided and paid for on the same date of service. Medicare rules state that code A4357 is included in the payment for code A4314. Based on this information, we decided that Medicare rules for coverage of the drainage bag have not been met. Therefore, we decided that the Plan does not have to pay for the drainage bag (A4357) provided to the enrollee on March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 10, 2022.
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional claim documents.
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve electronic connection (E2311) expandable controller (E2377) and 
expandable controller harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the medical necessity of all the components of this K0831 required by the enrollee to meet their medical 
functional and mobility needs throughout the day in their home. The Plan denied your request. The Plan says 
that although there are three requested power options (tilt, recline and elevating leg rests) there is not a medical 
need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 upgraded electronics. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing basic daily activities. The enrollee cannot perform pressure relief independently due to weakness 
and spasticity and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. The enrollee also requires power elevating leg rests for positioning of lower extremities and due to 
spasticity from a stroke. The complexity of the enrollees seating and positioning needs necessitates a more 
complex group 3 power wheelchair base. The expandable controller with harness and electronic connection are 
necessary to operate the group 3 power wheelchair base and the three power options, including, tilt, recline and 
elevating leg rests, via a joystick. Therefore, the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) is 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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve electronic connection (E2311) expandable controller (E2377) and expandable controller harness 
(E2313).  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 3, 2022, and billed under codes 80051, 82465, 82947 and 83880.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional claim information. The Plan submitted information to show based on the Medicare Practitioner Procedure to Procedure (PTP) Edits, there is a PTP edit between column 1 code 80053, and column 2 code 80051. Both codes were billed for the same date of service on two different claims. The Plan submitted the claims for review as well as the PTP Edit sheet showing the edit between the two codes. Procedure code 80051 was not billed with a modifier. Medicare National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) code edits prevent inappropriate payment of services that should not be reported together.
Each edit has a Column One and Column Two code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.
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 and when necessary, the appropriate modifier. In this case, this claim could not be paid as billed due to the omission of the required modifier that would allow a bypass of the PTP edit. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 3, 2022, and billed under codes 80051, 82465, 82947 and 83880.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D7953). 
 
You asked the Plan to pre-approve the dental service (D7953). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental service (D7953).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 32 additional occupational therapy visits. 
 
You asked the Plan to pre-approve occupational therapy visits. You say that the enrollee still requires 
occupational therapy due to significant pain to the bilateral shoulders and cervical area which are currently 
affecting their activities of daily living performance. The Plan denied your request. The Plan says 32 additional 
Occupational therapy visits 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 occupational therapy 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 that the enrollee has chronic shoulder pain while 
doing activities of daily living and instrumental activities of daily living. The enrollee has responded to 
occupational therapy with improved function. The enrollee has an established and effective home exercise 
program. Although the plan has approved 4 additional visits to complete home exercise training the enrollee 
does not require continued input from 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 occupational therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 32 additional occupational therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital admission and care. 
 
You asked the Plan to pre-approve acute inpatient hospital admission and care. You say that the enrollee is 
unable to complete physical therapy due to pain in right shoulder. You also say that the enrollee has already 
completed four weeks of physical therapy. The Plan denied your request. The Plan says the requested 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital admission and 
care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met 
in this case. Our physician reviewer found the approved surgery is not listed on the Inpatient Only list. The 
reviewer also found that there is no documentation provided to support the expectation the enrollee will require 
a greater than two midnight stay. Therefore, the reviewer found that the requested inpatient admission 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 acute inpatient hospital admission and care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient hospital admission and care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nuvasive Osteocel allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the allograft 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows the requested allograft is an effective and/or safe treatment for 
the enrollee's pathology of lumbar radiculopathy and spondylolisthesis. 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. Therefore, the requested Nuvasive Osteocel allograft 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Nuvasive Osteocel allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cerapedics I-Factor allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the surgery is approved and the allograft 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Cerapedics I-Factor 
allograft is considered experimental in nature. More research is needed to support its efficacy. The iliac crest 
bone graft is the gold standard of care. The Cerapedics I-Factor allograft is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Cerapedics I-Factor allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Spine ZIP device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Aurora ZIP device is 
considered experimental in nature. More research is needed to support its use. The services are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Aurora Spine ZIP device.