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

 
We decided that the Plan does not have to pre-approve self-administered drugs. 
 
You asked the Plan to pre-approve the medication. You say that you went to the hospital at your doctor's 
request. 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 self-administered drugs.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from January 8, 2018, through 
November 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to reimburse you for the 
services. The Plan denied your request. The Plan says the claim was untimely, and the submission did not meet 
the exception criteria guidelines. Additionally, the service on November 16, 2022, denied correctly for the 
procedure code missing or invalid. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until August 22, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Additionally, the service 
on November 16, 2022, denied correctly for the procedure code missing or invalid. Therefore, we decided that 
the Plan does not have to pay for the dental services provided from January 8, 2018, through November 16, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Kerecis omega3 skin substitute. 
 
You asked the Plan to pre-approve the Kerecis omega3 skin substitute. You say that when grafted onto 
damaged human tissue such as a burn or a wound, the fish skin graft recruits the body's cells, supporting the 
body's own ability to regenerate. You say that the fish skin is also a natural microbial barrier. The Plan denied 
your request. The Plan says the Kerecis omega3 skin substitute 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 the Kerecis omega3 skin substitute. Our 
reviewer says that the Kerecis omega3 skin substitute is not medically necessary. Our physician reviewer found 
that the requested skin substitute is 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 Kerecis omega3 skin substitute have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Kerecis omega3 skin substitute.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant surgery (69930). 
 
You asked the Plan to pre-approve a cochlear implant surgery. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee has normal hearing on one side, and profound hearing loss 
on the other side. 
 The Plan follows Medicare rules. Medicare rules say that cochlear implant surgery can be 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 cochlear implant surgery. Our 
reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found the record 
indicates that the enrollee has unilateral profound sensorineural hearing loss. 
 
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 cochlear implant surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cochlear implant surgery (69930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on April 27, 2023. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. CPT code 85060 has a status indicator of "B" and is not recognized 
by OPPS when submitted on an outpatient hospital Part B bill type 13X. The edit 62 is used when a code is not 
recognized by the OPPS and has a disposition of return claim to provider. All other claim lines available, 
including 38222, are denied due to return to provider (RTP) edit 62. Based on this information, we decided that 
Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that 
the Plan does not have to pay for the outpatient hospital services provided on April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BluePrint genetic testing (81599) provided on June 9, 2023. 
 
You asked the Plan to pay for BluePrint genetic testing. You say that this test was necessary and should be 
paid. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of BluePrint genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for BluePrint genetic testing (81599) provided on June 9, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87556, 87653, 87640, 87651, 87653, and 87798 for date of service March 3, 2023.

You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test. 

We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code with one unit of service should be used. Based on this information, we decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87556, 87653, 87640, 87651, 87653, and 87798 for date of service March 3, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve selective catheter placement, arterial system; initial third order or 
more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (36247). 
 
You asked the Plan to pre-approve selective catheter placement. You say that you are requesting 
reconsideration and have submitted medical records for review. The Plan denied your request. The Plan says 
that the records do not show the enrollee is enrolled in a clinical trial and is not recommended outside the 
context of clinical trials. 
 
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 selective catheter placement. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has benign prostatic hypertrophy. Prostate artery embolization has 
been requested to treat the condition as a minimally invasive procedure but has been denied as investigational. 
The Society of Interventional Radiologists have endorsed the procedure when done in experienced hands and 
the requesting physician has provided supporting literature. The American Urological Association has endorsed 
the procedure when appropriate but falls short of calling it the procedure of choice. Centers for Medicare & 
Medicaid Services allows the procedure and since the enrollee desires this minimally invasive procedure the 
request should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement have been met. Therefore, we decided that the Plan 
has to pre-approve selective catheter placement, arterial system; initial third order or more selective abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (36247).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulmonary services described by code 94760 performed 
on date of service September 12, 2023. 
 
You asked the Plan to pay for 94760. You say that 94760 should be paid as it was performed by your primary 
care provider and a referral should not be required. The Plan denied your request. The Plan says 94760 is 
denied because payment for this service it is bundled into payment for the office visit coded as 99204. 
 
The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of T on the 
MPFSDB are only paid if there are no other services payable under the physican fee schedule billed on the 
same date by the same provider. 
 
We looked at the file and Medicare rules. In this case we confirmed that procedure code 94760 has a status indicator of T on the physician fee schedule. This means that procedure code 94760 is only paid if no other 
services payable under the fee schedule were billed on the same date by the same provider. We confirmed that 
procedure code 99204, which is payable under the physician fee schedule, was billed on the same date of 
service, September 12, 2023, by the same provider. As such, the denial of 94670 is correct. Based on this 
information, we decided that Medicare rules for coverage of 94760 have not been met. Therefore, we decided 
that the Plan does not have to pay for the pulmonary services described by code 94760 performed on date of 
service September 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain.  
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is medically necessary.  
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record provided does not establish that 
the enrollee meets the diagnostic criteria of both AD and FTD or that the examination is being requested in the 
context of a clinical trial. The elements of the coverage criteria are not satisfied.   
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiological services provided to the enrollee on February 6,
2023, and billed with codes 71045 and 70450.

You asked the Plan to pay for this service. The Plan denied your request. The Plan says the enrollee is
incarcerated. Maximus overturned the Plans denial for insufficient information in the case file. The Plan
requested a reopen and provided the required additional information.

The Plan is correct in this case. Medicare does not pay for services provided to incarcerated enrollees. Based on
the information provided and our own confirmation on the governments inmate database, the enrollee was
incarcerated on the date of service. Therefore, we decided that the Plan does not have to pay for radiological
services provided to the enrollee on February 6, 2023, billed with procedure codes 71045 and 70450.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) and excision of tongue lesion (41112) 
provided on May 22, 2023. 
 
You asked the Plan to pay for an office visit and excision of tongue lesion. You say that the services should be 
covered. The Plan denied your request. The Plan says this provider is on the Medicare opt-out list. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit (99202) and excision of tongue lesion (41112) provided on May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skin color correction and the skin color correct each 
additional 20 centimeters.  
 
You asked the Plan to pre-approve the skin color correction and the skin color correct each additional 20 
centimeters. You say that the enrollee has had their left breast removed and reconstructed due to breast cancer. 
You say that the enrollee is only have the breast tattoo removed as part of their reconstruction surgery. You say 
that the enrollee is a cancer patient and not a cosmetic tattoo. The Plan denied your request. The Plan says the 
skin color correction and the skin color correct each additional 20 centimeters is considered cosmetic in nature.  
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.  
 
  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 skin color correction and the skin 
color correct each additional 20 centimeters. Our reviewer says that the skin color correction and the skin color 
correct each additional 20 centimeters is considered cosmetic in nature. Our reviewer found that the enrollee 
has a history of breast cancer and has undergone reconstruction including an areola tattoo. However, the 
records indicates that the requested procedure is cosmetic in nature and is insufficient to establish the medical 
necessity of the requested service. Also, the records do not establish the medical necessity and reasonableness, 
as defined by Medicare rules, of the requested service. Therefore, the elements of the coverage criteria are not 
satisfied, and the requested service is not recommended. 
 
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 skin color correction and the skin color correct each additional 20 
centimeters have not been met. Therefore, we decided that the Plan does not have to pre-approve the skin color 
correction and the skin color correct each additional 20 centimeters.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 home ventilator. 
 
You asked the Plan to pre-approve the Life2000 home ventilator. You say that the enrollee needs non-invasive 
ventilation due to chronic respiratory failure secondary to COPD that has caused high CO2 retention. You also 
say that BiPAP is not sufficient because the enrollee experiences shortness of breath throughout the day and is 
insufficient for their needs.   The Plan denied your request. The Plan says a home ventilator is not medically necessary for the enrollee 
because their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the Life2000 home ventilator. Our 
reviewer says that the Life2000 device is not medically necessary. Our physician reviewer found the enrollee 
has no documentation to support the need for a home ventilator. There are no trial or failure of BiPAP 
documented. Hence, no indication, per documentation nor data, that Life2000 home ventilator is required. This 
is not standard therapy nor recommended at this junction per documentation of the enrollee's disease. 
 
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 Life2000 home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Life2000 home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2330) provided on August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the service should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 23, 2023. 
Therefore, we decided that the Plan does not have to pay for the filling (D2330) provided on August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4618 and A7003 provided on August 29, 
2023. 
 
You asked the Plan to pay for procedure codes A4618 and A7003. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for procedure codes A4618 and A7003 provided on August 29, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you request reconsideration of the 
denied claim. You have submitted medical records for review. The Plan denied your request. The Plan says 
claims for E0675 will be denied as not reasonable and necessary.  
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that a live specimen was received for testing. 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. 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 lab services provided on October 21, 2022.