Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3; TheraSkin. 
 
You asked the Plan to pre-approve Kerecis Omega3; TheraSkin. You say that Kerecis Omega3; TheraSkin is 
medically necessary. The Plan denied your request. The Plan says the medical records indicate that the 
enrollee's wound is slowly improving with conservative wound therapy. 
 
The Plan follows Medicare rules. 
 
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 Kerecis Omega3; TheraSkin. Our 
reviewer says that Kerecis Omega3; TheraSkin is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee with a right ankle wound following a fall complicated by 
injection and needing antibiotics and surgery followed by general conservative wound care. The provided 
recent records describe the patient having also had a prior TheraSkin graft placed and recently responding, 
albeit slowly, to conservative wound care. Therefore, this request for Kerecis Omega3; TheraSkin does not 
meet the Medicare LCD coverage criteria due to lack of failed response to conservative therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis Omega3; TheraSkin have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Kerecis Omega3; TheraSkin.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NovaBone MacroFORM allograft (20930). 
 
You asked the Plan to pre-approve NovaBone MacroFORM allograft. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 NovaBone MacroFORM allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Novabone allograft is experimental. More research is needed.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NovaBone MacroFORM allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve NovaBone MacroFORM allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kidney transplant to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a kidney transplant. You say that you want to be a replacement on  
medical center kidney transplant list because it is better for you. The Plan denied your request. The Plan says 
the services are available with Medicare-approved transplant center and a Plan Center of Excellence (COE) for 
kidney/liver transplantation. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a kidney transplant to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on October 25, 2022, billed with 
codes 87502, 87631, 87498, 87483, and U0004. 
 
You asked the Plan to pay for the panel testing billed. You say that medical records were provided. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. The provided panel testing was not billed with a single code as 
required. Based on this information, we decided that Medicare rules for coverage of the panel testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing provided on 
October 25, 2022, billed with codes 87502, 87631, 87498, 87483, and U0004.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 6, 2023, billed with codes 99152 and 99153. 
 
You asked the Plan to pay for procedure codes 99152 and 99153. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting, 
and code 99152 is not separately payable. 
 
Medicare rules say that providers/suppliers must report services correctly. Procedures should be reported with 
the Current Procedural Terminology (CPT) code that describes the services performed. The rules also state that 
the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not payable to the physician for 
services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Also, code 99152 is packaged into 
payment of the primary procedure. Therefore, we decided that the Plan does not have to pay for the additional 
moderate sedation time provided on date of service June 6, 2023, billed with codes 99152 and 99153.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Isto Biologic InQu, Influx Sparc allografts, and bone 
marrow aspirate (20939). 
 
You asked the Plan to pre-approve Isto Biologic InQu, Influx Sparc allografts, and bone marrow aspirate. You 
say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 Isto Biologic InQu, Influx Sparc 
allografts, and bone marrow aspirate. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found osteopromotive allograft is 
experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Isto Biologic InQu, Influx Sparc allografts, and bone marrow aspirate have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Isto Biologic InQu, Influx Sparc 
allografts, and bone marrow aspirate (20939).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 75774 billed for date of 
service March 21, 2023. 
 
You asked the Plan to pay for 75774. You say that 75774 should be paid as billed because it was reported 
correctly and is supported in the medical record. The Plan denied your request. The Plan says 75774 is denied 
because it is 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. 
 
In this case, the CPT Code Manual definition of code 75774 is angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure). 
 
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 75774. Our reviewer says that 75774 is not supported in the 
documentation. Our reviewer found the record does not support selective angiography was performed in any 
additional selective arterial vessel. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75774 have not been met. Therefore, we decided that the Plan does not have to 
pay for the radiology services coded as 75774 billed for date of service March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code G0481 billed for date of service July 27, 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 billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and noted that this claim denied because
the provider billed this service inappropriately. The Plan states the initially denied this service as being
previously paid; however, the provider should have billed CPT G0480 for payment consideration. After
clinical review of the medical records, the service was determined to be coded incorrectly. This is a billing
error on the part of the provider and the service is not reimbursable. According to our review, the records
do not include definitive laboratory results for 8 to 14 drug classes to support the coding criteria for the
code billed on date of service. There was a total of 6 drug classes tested based on the laboratory results
received.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid as billed due to an error with the code billed.
There is a more appropriate code for number of drug classes tested. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0481 billed
for date of service July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 28, 2022.

You asked the Plan to pay for this testing. 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 that per the
DEX Diagnostic Exchange Registry, code 81479 was not billed with Z-code ZB1CW as required.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that providers must report
services correctly. In this case, code 81479 was not reported with the required Z-code. Medicare rules for
coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic
testing provided to the enrollee on April 28, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the 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 
service is not medically necessary. Our physician reviewer found the Plan requires a trial of an injectable 
bisphosphonate, Pamidronate or Zoledronic acid, before they will approve the requested drug. In this case, the 
patient has not tried and failed a required drug. There is no documentation provided indicating that the plans 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for n to pay for arthrocentesis, aspiration and/or injection, major
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance rendered on
September 7, 2022.

You asked the Plan to pay this claim as billed. 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 that
Maximus did not apply the correct billing criteria. The Plan demonstrated that code 20610-59-RT, an
arthrocentesis, aspiration and/or injection for a major joint or bursa (shoulder, hip, knee, subacromial bursa),
without ultrasound guidance is documented in the operative note submitted for review; however, this procedure
is considered inclusive to CPT code 29880-RT, a surgical knee arthroscopy, with meniscectomy (medial AND
lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty),
for the same or separate compartment(s) when performed; therefore the code cannot be verified. The Plan states
code 20610-59-RT is an edited pair with approved code 29880.

Modifier 59 should only be used if no other modifier more appropriately describes the relationships of the two
or more procedure codes. NCCI PTP edits define when two procedure HCPCS/CPT codes may not be reported
together except under special circumstances. If an edit allows use of NCCl-associated modifiers, the two
procedure codes may be reported together when the two procedures are performed at different anatomic
sites or different patient encounters. Carrier (A/B MAC processing practitioner service claims) processing
systems utilize NCCl-associated modifiers to allow payment of both codes of an edit. Modifier 59 and other
NCCI-associated modifiers should not be used to bypass an NCCI PTP edit unless the proper criteria for use of
the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCClassociated
modifier used.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid as billed due to an error with the association
between the two codes and the reported 59 modifier. Medicare rules for coverage of this claim as billed have
not been met. Therefore, we decided that the Plan does not have to pay for n to pay for arthrocentesis,
aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without
ultrasound guidance rendered on September 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure (22612, 22840). 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met because 
use of this device as a stand-alone procedure has not been shown to be safe and effective in long term studies. 
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Minuteman device is experimental. More research is needed. 
 
   
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure (22612, 22840).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for magnetic resonance imaging (MRI) of the chest
for the enrollee.

You asked the Plan to provide coverage for an MRI of the chest. The Plan denied your request. The Plan says
the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus reviewed the wrong service. The Plan noted that the submitted clinical records
for the MRI of the chest was for hemochromatosis and to rule out iron overload. This is not listed in the
coverage guidelines as criteria and the request was denied. The Plan felt the ordering physician may have asked
for the wrong MRI to be covered. This was listed in the letter dated April 23, 2023, advising that a Cardiac
MRI may have been the intention and guidance to submit that request for coverage. The IRE physician
reviewer decided to overturn the Plan's decision to deny the MRI of the chest. However, the physician reviewer
noted, "A cardiac magnetic resonance imaging is superior to the other diagnostic test since
it can quantitatively assess myocardial iron load." A Cardiac MRI was never denied.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of an MRI of the chest were met.
Therefore, we decided that the Plan does not have to provide coverage for magnetic resonance imaging (MRI)
of the chest for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a filling on tooth 8 (D2335). 
 
You asked the Plan to pre-approve the dental services. You say that this 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 April 14, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a filling on tooth 8 (D2335).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee has exceeded their benefit for this calendar year. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 5, 2023, 
through September 7, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MInuteman device (22840, 22612). 
 
You asked the Plan to pre-approve a MInuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a MInuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental. More research is needed. 
 
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 MInuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MInuteman device (22840, 22612).
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 June 22, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 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 June 22, 2023.