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

 
We decided that the Plan does not have to pre-approve routine laboratory testing, routine venipuncture, 
injectable medication, and intravenous infusion of Ferumoxytol. 
 
You asked the Plan to pre-approve routine laboratory testing, routine venipuncture, injectable medication, and 
intravenous infusion of Ferumoxytol. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested services and drug are not medically necessary. 
 
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 routine laboratory testing, routine 
venipuncture, injectable medication, and intravenous infusion of Ferumoxytol. Our reviewer says that the 
documentation does not support that the requested services and drugs are medically reasonable or necessary. 
Our physician reviewer found the enrollee does not have evidence of iron deficiency anemia whose treating 
doctor would like to use intravenous (IV) iron. There is no clinical evidence of iron deficiency at this time. 
Therefore, the requested drug and related services are not medically necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of routine laboratory testing, routine venipuncture, injectable medication, and 
intravenous infusion of Ferumoxytol have not been met. Therefore, we decided that the Plan does not have to 
pre-approve routine laboratory testing, routine venipuncture, injectable medication, and intravenous infusion of 
Ferumoxytol.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knees. X-rays demonstrate mild/mod degenerative osteoarthritic 
changes. The documentation does not support that the enrollee has tried and failed Synvisc, Durolane, and 
Gelsyn-3. The documentation does not support that Synvisc, Durolane, and Gelsyn-3 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support a history of osteoporotic fracture or 
that the enrollee has tried and failed zoledronic acid. The documentation does not support that zoledronic acid 
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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 73130-RT, 93005, and 93041-59 billed for date of 
service July 2, 2023. 
 
You asked the Plan to pay for codes 73130-RT, 93005, and 93041-59. You say that these are payable codes. 
The Plan denied your request. The Plan says these codes are not paid separately. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, 
meaning that they are STV-packaged services.  These disputed codes were billed on the same claim with a code 
that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 73130-RT, 93005, and 93041-59 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 73130-RT, 93005, and 93041-59 billed for date of service July 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure received its 
initial Food and Drug Administration (FDA) clearance in 2016 and that clearance means the procedure is safe 
and efficacious. The Plan denied your request. The Plan says the Intracept procedure is considered 
experimental and investigational because of insufficient evidence of the effectiveness. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The cause of 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx (0339U) provided October 10, 2022.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for
medical necessity. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The
Plan notes the technical assessment for SelectMDx was not effective until February 17, 2023. The date of
service was October 10, 2022.

The Plan also notes on the date of service for this SelectMDx test, only Progensa PCA3 and Confirm MDx had
met the coverage criteria as stipulated in the LCA.

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 testing was not available for coverage on the date if was performed.
Therefore, we decided that the Plan does not have to pay for the SelectMDx (0339U) provided October 10,
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, for 15-21 drug classes (G0482) 
provided April 5, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the billed diagnosis codes are covered codes 
for procedure codes 80307, G0482. Kindly process the claim towards payment. The Plan denied your request. 
The Plan says under Medicare rules, the number of definitive urine drug classes requested are not medically 
necessary.  
 
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 G0482 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays and enzymatic methods (e.g., alcohol dehydrogenase)), (2) 
stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including 
metabolite(s) if performed. 
 
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 the laboratory service. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found the 
enrollee was being prescribed alprazolam, morphine sulfate ER and tramadol for chronic pain and anxiety. 
Although drug testing for this enrollee appears to be appropriate, only 3 drug classes were warranted for 
definitive testing at this time based on the provided documentation and not the required 15-21 drug classes to 
justify the code, G0482. Therefore, this request for such will be considered not medically necessary.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing, for 15-21 drug classes (G0482) provided April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Select MDx for prostate cancer (0339U) provided to the
enrollee on November 16, 2022.

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. The
Plan requested a reopen and noted Maximus did not apply the correct criteria. The Plan notes the technical
assessment for SelectMDx was not effective until February 17, 2023. The date of service in this case was
November 16, 2022, and therefore did not meet the billing criteria.

The Plan also notes on the date of service for this SelectMDx test, only Progensa PCA3 and Confirm MDx had
met the coverage criteria as stipulated in the LCA.

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 testing was not available for coverage on the date if was performed.
Therefore, we decided that the Plan does not have to pay for Select MDx for prostate cancer (0339U) provided
to the enrollee on November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Trionic walker with all terrain wheels, all terrain 
brake, with seat and basket (E0156, E1399). 
 
You asked the Plan to pre-approve the walker. You say that for your mental health you like to garden be in 
your back yard. You feel this walker would be safer for you.  The Plan denied your request. The Plan says the 
notes do not show that a Trionic walker with all terrain big wheels is medically necessary or appropriate.  
 
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 walker. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested item does not meet the criteria of Local Coverage Determination (LCD) Walkers 
L33791 as the Trionic walker is for outdoor use. The enrollee does not require the walker to complete activities 
of daily living.  
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Trionic walker with all terrain wheels, all terrain brake, with seat and basket (E0156, 
E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97535 billed for date of service May 12, 
2023. 
 
You asked the Plan to pay for the billed service. 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. 
 
 In this case, the CPT Code Manual definition of code 97535 is self-care/home management training (e.g., 
activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and 
instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 
minutes 
 
We find that CPT code 97535 is not supported in the medical record. Specifically, the records do not document 
this service was provided on the date at issue. Based on this information, we decided that Medicare rules for 
coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97535 billed for date of service May 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic side guards for a wheelchair. 
 
You asked the Plan to pre-approve plastic side guards. You say that this is needed. The Plan denied your 
request. The Plan says this component 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 plastic side guards. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not show that removable plastic side guards are safe and effective, not 
mainly for the convenience of the enrollee or physician, not experimental or investigational, and are furnished within accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of plastic side guards have not been met. Therefore, we decided that the Plan does 
not have to pre-approve plastic side guards for a wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (Umano Ook Snow bed). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee requires positioning of 
the body in ways not feasible with a standard hospital bed. The Plan denied your request. The Plan says this is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (Umano Ook Snow bed).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 8, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the codes billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on April 5, 2023.

You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee.

The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the rules section of this letter 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 pay for the definitive UDT for 15-21 drug classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the documentation did not reveal a need to do perform definitive testing as there was no suggestion of illicit drug use or drug misuse or having abnormal unexpected presumptive drug screening results. Also, only one drug class was being taken making the 15-21 drug class testing excessive for this patient. Therefore, the code, G0482 will be considered not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the definitive UDT for 15-21 drug classes have not been met. Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on April 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical performance tests provided on June 12, 2023. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services requested are experimental and investigational. 
 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 pay for the therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the documentation does not reveal extenuating factors in this 
enrollee's condition that would require this STAT Trans-Mobile ancillary computerized Physical Performance 
Evaluation service rendered on the same day STAT for June 12, 2023, over a thorough office-based physician 
musculoskeletal and neurologic examination. The requested STAT mobile computerized Physical Performance 
Evaluation exceeds the enrollee's medical needs.    
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the physical performance tests provided on June 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spinal surgery (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that bone marrow aspirate is experimental when used as bone graft material.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spinal surgery (20939).