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

 
We decided that the Plan has to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says that in order for 
patients with arthritis of the knee to have more knee injections, it is necessary to have significantly less pain 
and better movement of the knee after previous injections of the knee. The Plan also says that the last Synvisc 
injection was administered on December 17, 2021, and the documentation does not indicate how the enrollee 
responded to the previous injections. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that 
Euflexxa is medically reasonable and necessary for the enrollee. Our physician reviewer found in this case, the 
last viscosupplementation injection (Synvisc) was administered on December 17, 2021. The documentation 
indicates the enrollee had a positive response. Our reviewer also found that the documentation supports that 
Euflexxa is safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have been met. Therefore, we decided that the Plan has to pre-approve 
Euflexxa (J7323).  
 
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 pre-approve a portable oxygen concentrator. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules 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 is 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 a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for September 30, 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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 31574 
provided on September 30, 2022. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99214 billed for 
September 30, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility care provided from December 21, 2022, to 
December 31, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that this should be covered by Medicare. 
The Plan denied your request. The Plan says that the enrollee exhausted the 100 days of the SNF benefit and 
was admitted to an inpatient hospital on December 31, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the enrollee met the 100-day benefit limit, but the 
documentation included in the case file only shows that there were 60 covered SNF days prior to the dates at 
issue. There is also no documentation of the inpatient admission beginning on December 31, 2022. Therefore, 
we decided that the Plan has to pay for skilled nursing facility care provided from December 21, 2022, to 
December 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87641 billed for date of service 
September 16, 2022. 
 
You asked the Plan to pay for procedure codes 87150 and 87641. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says these services are not supported for separate 
payment. 
 
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 87150 and 87641 is a column II code to column I code 87500 and 
87801; however, 87150 and 87641 was billed with a modifier.  
 
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 codes 87150 and 87641. Our reviewer says that 
the XU modifier is not supported with these codes for separate payment. Our reviewer found the laboratory 
report does not include documentation to support that these services were unusual non-overlapping services. 
Therefore, these codes and modifiers cannot be verified. 
 
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 codes 87150 and 87641 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87150 and 87641 billed for date of service September 
16, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA) (64635). 
 
You asked the Plan to pre-approve a facet joint RFA. 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 follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 facet joint RFA. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has not had the 
required confirmatory medial branch block (MBB). The review has determined that the enrollee does not meet 
the coverage criteria detailed in the 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 a facet joint RFA have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint radiofrequency ablation (RFA) (64635).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to adjust the vision benefit any further for the enrollee.
You asked the Plan to have any additional money owed on these glasses applied to the Out-of-Pocket benefit or Spending Account Card. You stated you tried to use with card with the optometrist, but it would not work. You say that you would like the enrollee reimbursed for the out-of-pocket costs paid against the benefit card. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
First the Plan notes they contacted the provider regarding their issues with the benefit card and the provider has now been cleared to use those case. The Plan noted that two claims from the vision provider with a $264.00 enrollee liability. The Evidence of Coverage explains that the enrollee is responsible for any amount over the $300 retail price for the frames and lens package. The Explanation of Benefits shows that the Plan allowed $444.00 towards this claim; the retail price is $630.00. The Plan paid $180 the provider discount is $186.00, leaving the $264.00 enrollee liability. The Plan also contacted the vision provider on May 9, 2023, and was advised the additional $49.99 out-of-pocket expense was for a $30 Scratch Protection and $20 Polishing Edges that was not a covered benefit in the vision plan. That is why the provided billed the enrollee directly for the non-covered services. The Plan further notes if the enrollee did not want those services the enrollee could have requested a refund.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan explains limitations with the vision benefit. At this point we find the enrollee has been asked to pay for those vision services provided that exceeded the benefit and were not covered under the Plan contract. Therefore, we decided that the Plan does not have pay any further reimbursement to the enrollee or allow application of services paid to the OOP benefit.
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 medically necessary, and this 
treatment will be beneficial to the enrollee in the long run. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 the acute inpatient hospital care provided from January 20, 
2023, to January 21, 2023. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that you requested authorization for 
this inpatient stay, but it was denied. You also say that you still believe that all services provided were 
medically necessary to ensure the health and well-being of the enrollee. The Plan denied your request. The Plan 
says an inpatient stay was 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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the documentation does not support inpatient admission, as this clinical 
scenario could have been addressed with a lower level of care. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from January 20, 2023, to January 
21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of services December 
14, 2022, to December 21, 2022. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the NOA was 
not received timely.  
 
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 December 13, 2022. The NOA was not received by the Plan until January 
13, 2022. 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 care billed for 
dates of services December 14, 2022, to December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87651, 87899 and 87900 billed for date of 
service December 21, 2022. 
 
You asked the Plan to pay for procedure codes 87651, 87899 and 87900. You say that these services were 
necessary and were reported appropriately. The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 codes 87651, 87899 and 87900. Our reviewer says 
that these codes are not supported in the records provided. Our reviewer found the laboratory report does not 
include documentation or results for any of these services. 
 
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 codes 87651, 87899 and 87900 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87651, 87899 and 87900 billed for date of 
service December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E2621, 
K0108, K0862, E0955, E1007, E1012, E1028, E2311, E2313, E2363, E2377, E2607). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
provided records do not support that the enrollee is high risk for skin breakdown, has a history of pressure 
ulcer(s) or has had skin flap surgery. Records do not document the enrollee performs bladder self-
catheterization and is unable to transfer independently or that the enrollee has increased muscle tone or 
spasticity to meet criteria for the power tilt and/or recline and thus the multiple power option base. As the 
requested wheelchair base does not meet Medicare coverage criteria, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E2621, K0108, 
K0862, E0955, E1007, E1012, E1028, E2311, E2313, E2363, E2377, E2607).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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 kyphoplasty is covered when specific criteria are 
met. 
 
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 enrollee is being treated for L3 and 
L4 compression fractures. Detailed documentation is not evident regarding a progression of the body height 
loss at L3, greater than 25 percent vertebral body height loss at L3, or kyphotic deformity. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of retropulsion at L4. The MRI from July 27, 2023 noted that 
the L4 wedge compression fracture has progressed since the computed tomography (CT) scan on August 29, 
2022, indicated that this is not an acute or subacute fracture. The criteria for coverage are not met and the 
kyphoplasty is not reasonable or medically necessary at this time. 
 
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 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 billed for July 29, 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 procedure code 95822 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. 
 
In this case, the CPT Code Manual definition of code 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
We find that CPT code 95822 is not supported in the medical record. Specifically, there is no documentation of 
an EEG recording in coma or sleep only. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95822 billed for July 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital 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 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 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 procedure is currently approved as an ambulatory procedure. There is 
no documentation provided to support the expectation you will require a greater than 2 midnight stay.  
 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records in this case 
do not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as opposed 
to a bilevel positive airway pressure (BiPAP) device with average volume assured pressure support and a back-
up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).