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

 
We decided that the Plan does not have to pre-approve CALR, JAK2, and MPL testing. 
 
You asked the Plan to pre-approve genetic testing. You say that negative test results give medical necessity to 
then proceed to additional testing. The Plan denied your request. The Plan says records do not show primary 
myelofibrosis and the provider suspects leukocytosis most likely inflammatory due to rheumatoid arthritis and 
tobacco use given fluctuation and mild nature of the leukocytosis. 
 
The Plan follows Medicare rules. Medicare rules state that CALR, JAK2, and MPL testing may be covered if 
certain 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 genetic testing. Our reviewer says that 
the enrollee does not meet criteria for this testing. Our physician reviewer found if the plan is to monitor the 
enrollee with follow-up complete blood count (CBC), it is not necessary to perform a next generation 
sequencing at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CALR, JAK2, and MPL testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of paclitaxel. 
 
You asked the Plan to pre-approve paclitaxel. You say that this will improve the enrollee's likelihood of 
response. The Plan denied your request. The Plan says this is not supported by the Food & Drug 
Administration (FDA) or drug compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 paclitaxel. Our reviewer says that the 
enrollee does not meet criteria for use of paclitaxel. Our physician reviewer found paclitaxel is not Food & 
Drug Administration (FDA) for the enrollee's diagnosis. This use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paclitaxel have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of paclitaxel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 3, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 3, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ provided on May 30, 2023. 
 
You asked the Plan to pay for procedure code 81345-GZ. 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 state that items submitted with a GZ modifier shall be 
denied automatically and will not be subject to complex medical review. 
 
We find that CPT code 81345 is not supported in the medical record. Specifically, this service includes the GZ 
modifier, which means that this service does not meet the criteria for Medicare coverage. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 
81345-GZ have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
81345-GZ provided on May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 3, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 3, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 3, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of November 3, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 3, 
2023, as she was not a danger to herself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 3, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 3, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve internal bleaching (D9974). 
 
You asked the Plan to pre-approve internal bleaching. You say that this tooth is discolored, and you would like 
it brought back to its original color. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
internal bleaching (D9974).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 4 routine transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the services are medically 
necessary for you to make your appointments. The Plan denied your request. The Plan says you have exhausted 
your yearly benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 4 routine transportation trips.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee is unable to try other medications due to 
medical condition limiting their ability to be safely compliant. The Plan denied your request. The Plan says the 
enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 step 
therapy criteria for Prolia have not been met. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has tried and failed the preferred drug, zoledronic acid. The reviewer found that 
the documentation does not support that zoledronic acid would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria 
have not been met. 
 
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 (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to pay for the Bupivacaine injection provided to the enrollee on March 2,
2023.

You asked the Plan to pay for this injection. You say that this claim should be paid. The Plan 
denied your
request. The Plan says this drug is not separately payable. Maximus overturned the Plans denial. 
The Plan requested a reopen and provided additional information. The Plan noted that the unlisted 
code J3490 for was denied because Bupivacaine is a local anesthetic agent that cannot be separately 
reimbursed from the injection procedure 64405 that was billed on the same claim. Per Medicare 
Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic 
injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV 
infusion or injection, other than hydration, is for the administration of substances/drugs. The 
fluid used to administer the drug (s) is incidental hydration and
is not separately payable. If performed to facilitate the infusion or injection or hydration, the 
following services and items are included and are not separately billable:
1. Use of local anesthesia;
2. IV start;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion; and
5. Standard tubing, syringes, and supplies.
Payment for the above is included in the payment for the chemotherapy administration or
nonchemotherapy injection and infusion service.

Based on these billing guidelines, payment for the local anesthetic is included in the payment for the
chemotherapy administration or nonchemotherapy injection and infusion service.

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, it has been confirmed that payment for this drug code is included in the
payment for the administration and is not separately payable. Medicare rules for coverage of this injection
separately have not been met. Therefore, we decided that the Plan does not have to pay for the Bupivacaine
injection provided to the enrollee on March 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block in the right knee. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee has tried and failed 
conservative treatments. You say that this is necessary to better manage the enrollee's knee pain. The Plan 
denied your request. The Plan says there is insufficient scientific evidence to support the medical necessity of 
this service as it has not been shown to improve health 
outcomes. 
 
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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered experimental for the enrollee's condition. Therefore, the reviewer found that the requested genicular nerve block 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 the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve block in the right knee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 27, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11043, 20902, 32551, 64620, and 97606 
billed for date of service June 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the services. The 
Plan denied your request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that submitted claims in 
which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is 
evidence justifying the excess units.  
 
In this case, the MUE for CPT code 64620 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. The records ds not clearly document the rationale for excess units. Based on this 
information, we decided that Medicare rules for coverage have not been met. 
 
In this case, the CPT Code Manual definition of code 11043 is debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. We find that code 11043 is 
not supported. debridement of tissue in the surgical field of another musculoskeletal procedure, such as billed 
code 32653, is not separately reportable. The records do not show that code 11043, billed with the -59 modifier 
was a significantly separate procedure. 
 
The CPT Code Manual definition of code 20902 is bone graft, any donor area; major or large. We find that 
code 20902 is not supported. The bone graft is not separately reportable unless the graft is harvested from a 
separate incision. 
 
The CPT Code Manual definition of code 32551 is tube thoracostomy, includes connection to drainage system 
(e.g., water seal), when performed, open (separate procedure). We find that code 32551 is not supported. CMS 
does not allow separate reporting of a procedure designated as a "separate procedure" when it is performed at 
the same patient encounter as another procedure. 
 
The CPT Code Manual definition of code 97606 is negative pressure wound therapy (e.g., vacuum assisted 
drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound 
assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square 
centimeters. We find that code 97606 is not supported. The records do not clearly document if the negative 
pressure wound therapy was used with durable medical equipment or non-durable medical equipment. 
 
We looked at the file and the rules. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 11043, 20902, 32551, 64620, and 97606 billed for date of service June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1852, L2397). 
 
You asked the Plan to pay for the knee brace. You say that the item is medically necessary. 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 a knee orthosis is covered under certain conditions: 
1. Knee orthoses are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) 
2. Knee orthoses are also covered for a beneficiary who is ambulatory and has knee instability 
3. knee instability must be documented by examination of the beneficiary and objective description of joint 
laxity (e.g., varus/valgus instability, anterior/posterior Drawer test 
4. Knee orthoses will be denied as not reasonable and necessary when the beneficiary does not meet the above 
criteria for coverage. For example, they will be denied if only pain or a subjective description of joint 
instability is documented. 
 
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 knee brace. Our reviewer says that the 
items are not medically necessary. Our reviewer found that there is no recent injury, surgery or instability 
documented in the records submitted. 
 
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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee brace (L1852, L2397).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on April 21, 2023, to, April 
23, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that that it was miscoded and that you had took 
your blood pressure medication that was given to you in the hospital. The Plan denied your request. The Plan 
says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 pay for self-administered drugs provided 
on April 21, 2023, to, April 23, 2023.  
 
Benefits for self-administered drugs 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 pre-approve partial upper and lower dentures. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 September 30, 2020. 
Therefore, we decided that the Plan does not have to pre-approve partial upper and lower dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cover and transport feature for an approved power 
wheelchair (K0108). 
 You asked the Plan to pre-approve the cover and transport feature. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The cover at issue in this appeal does not serve a purpose that is primarily medical in nature. The transport 
feature is for use outside the home and is not covered. Therefore, we decided that the Plan does not have to pre-
approve a cover and transport feature for an approved power wheelchair (K0108).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Eylea HD. 
 
You asked the Plan to pre-approve Eylea HD. You say that the enrollee has had a setback while on Eylea 2mg. 
You say that the enrollee has had increase hemorrhage. You also say that the enrollee should not continue this. 
The Plan denied your request. The Plan says that the records do not show why Eylea cannot be used. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Eylea HD. Our reviewer says that the 
requested use of Eylea HD is medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of exudative age-related macular degeneration with active choroidal 
neovascularization. The Food and Drug Administration has stated that the requested drug is indicated for the 
enrollee's condition. The record provided is sufficient to establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested change in drug dose and formulation. Therefore, the reviewer 
found that the requested use of Eylea HD is medically reasonable and 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 Eylea HD have been met. Therefore, we decided that the Plan has to pre-
approve Eylea HD.  
 
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.