Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0157, G0159, G0299, 
Q5001) provided on March 14, 2023, to April 11, 2023. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 14, 2023. The NOA was not received by the Plan until May 24, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0157, G0159, G0299, Q5001) provided on March 14, 2023, to April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the genicular nerve 
branches (64624). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee has had this procedure done once per 
year for the past three years. You also say that they had excellent results. The Plan denied your request. The 
Plan says this service is considered experimental and therefore is not covered. 
 
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 RFA. Our reviewer says that the 
requested RFA for genicular nerve branch is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical 
trials. Therefore, the reviewer found that the requested RFA for genicular nerve branch is deemed not 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) for the genicular nerve branches (64624).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin eye injections.
You asked the Plan to pre-approve Avastin. You say that the medication is medically necessary. The Plan denied your request. The Plan says that they denied the injection itself because whether, or not, another injection is needed is dependent upon the provider's examination. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria. The Plan is correct in this case. 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 Avastin have been met. Your physician has not provided an order for Avastin eye injections. Therefore, we decided that the Plan does not have to pre-approve Avastin eye injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 billed for date of service February 1, 
2023. 
 
You asked the Plan to pay for procedure code 83520. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83520 is bundled into payment for code G0481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 83520 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83520 billed for date of service February 1, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 28, 
2022, through November 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.          
 
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with weakness and swelling in 
both legs. The enrollee was diagnosed with acute congestive heart failure. His vital signs were stable with 
normal oxygenation and no use of accessory muscles or distress. He had a clear lung examination and a  
chest x-ray without an acute pulmonary process. There was no evidence of infection or acute coronary 
syndrome. He was treated with diuresis with improvement in symptoms. As the enrollee did not have 
respiratory failure or acute renal failure, only renal insufficiency, without other acute issues requiring 
hospitalization, it was not expected that he would have required hospital care that would have likely crossed 
two midnights due to the low complexity and low severity of his condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from October 28, 2022, through November 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no 
complex nursing or rehabilitation needs.  The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, 
tracheostomy management or neurogenic bowel and bladder management. His medical and rehabilitation needs 
do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. The enrollee 
has had a mild decline from his baseline level of function and may benefit from occupational and physical 
therapies as well as supervision and assistance, but he does not require the intensity of therapies provided in an 
acute inpatient rehabilitation facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you will be discharged from the hospital and your 
doctor ordered that it will be best for you to stay at a skilled nursing facility. You say you just had surgery and 
there are no family members that can take care of you. The Plan denied your request. The Plan says you do not 
meet Medicare guidelines for services in a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, can be provided at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. 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 C2-3 posterior cervical fusion. 
 
You asked the Plan to pre-approve a posterior cervical fusion. You say that enrollee is having difficulty driving 
her car because she cannot turn her neck to check blind spots or turn to look left or right. The Plan denied your 
request. The Plan says the MRI findings of cervical stenosis do not correlate with the planned surgery. 
 
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 posterior cervical fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no correlation between physical exam and magnetic resonance 
imaging (MRI) findings. There is no stenosis of instability on imaging at the C2-3 level. 
 
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 posterior cervical fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a C2-3 posterior cervical fusion.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn. 
 You asked the Plan to pre-approve Gelsyn. You say that you have osteoarthritis and are in a lot of pain and 
have tried and failed a trial of Synvisc. The Plan denied your request. The Plan says there are no records from 
your prescriber that shows you've tried one of the preferred drugs Monovisc, Orthovisc, Synvisc or Synvisc 
One, or that you have medical reasons that prevent you from using one of them. 
 
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 Gelsyn. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the requested medication is a new start. 
The provided records do not indicate that you have tried and failed the Plan's preferred step one alternatives 
Monovisc, Orthovisc, Synvisc or Synvisc One. The record does not indicate that you have a contraindication to 
or would have an adverse effect from the plan's preferred step one alternatives. The elements of the coverage 
criteria are not satisfied. The requested service cannot be 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 Gelsyn have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Gelsyn.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detoxification services provided from April 4, 2023, to 
April 9, 2023.  
 
You asked the Plan to pay for the detoxification services. You say that this care was medically necessary and 
should be covered.  The Plan denied your request. The Plan says the provider's Medicare certification number 
is required to process this claim.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.  
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The provider number indicates this is a substance abuse facility which cannot enroll in the program.  
Therefore, we decided that the Plan does not have to pay for the detoxification services provided from April 4, 
2023, to April 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental gradient pressure pneumatic appliance, half 
leg (E0673) and a non-segmental pneumatic appliance for use with a pneumatic compressor (E0666). 
 
You asked the Plan to pre-approve the pneumatic appliances. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says a requested pneumatic pump was 
appealed separately and was denied; therefore, the appliances are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if the base PCD is not covered, related 
accessories are 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 pneumatic appliances have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a segmental gradient pressure pneumatic appliance, half leg (E0673) and a non-segmental 
pneumatic appliance for use with a pneumatic compressor (E0666).
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 2, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were rendered to the patient, so this 
claim should be paid. The Plan denied your request. The Plan says these services were not billed correctly. 
 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 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 rendered on April 27, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 83520: 
 
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that these codes require the records to 
have a complete description of the "not otherwise specified" part of the code. The medical records provided do 
not include the laboratory tests that were ordered. The codes cannot be validated. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 83520 and 87798 rendered on April 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Docetaxel and Carboplatin injections. 
 
You asked the Plan to pre-approve Docetaxel and Carboplatin injections. You say that the requested drugs are 
medically necessary for the enrollee's diagnosis. The Plan denied your request. The Plan says the drugs are not 
FDA-approved for the requested use. 
 
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 Docetaxel and Carboplatin injections. 
Our reviewer says that the requested drugs do not meet the criteria for approval. Our physician reviewer found 
the enrollee has prognostic stage II2 invasive ductal carcinoma of the left breast. The requested use of these 
drugs is not FDA-approved. The use of this drug for the enrollee's cancer is not supported by one of the major 
drug compendia, or by clinical research that appears 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 Docetaxel and Carboplatin have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Docetaxel and Carboplatin injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to par for the motor-assist exercise system. 
 
You asked the Plan to par for the motor-assist exercise system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to par for the motor-assist exercise system.