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

 
We decided that the Plan does not have to pre-approve Sucralfate Suspension 1gm/10ml. 
 
You asked the Plan to pre-approve Sucralfate Suspension. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Sucralfate Suspension 
1gm/10ml.  
 Benefits for Sucralfate Suspension 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for S2900.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denial 
was processed correctly. 
 
We decided that the Plan has to pay for 27447.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has denied stating there is a deductible for anesthesia services rendered 
at an out-of-network provider. The denied code - CPT 27447 - is not an anesthesia code. It is a code 
representing "Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without 
patella resurfacing (total knee arthroplasty)." The anesthesia deductible would not apply to this code for this 
reason. Additionally, an anesthesia deductible would not apply in this case, as the cited anesthesia deductible is 
for dental service. Knee arthroplasty is not a dental service. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
27447.  
 
We also decided that the Plan does not have to pay for S2900. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
this code is not valid for Medicare purposes. 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 
S2900. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac joint injection. The Plan denied your request. The Plan says the 
medical records we received did not show the injection therapy is medically necessary. The records did not 
show that the enrollee has failed to respond to three (3) months of conservative management, which may 
consist of medications, manipulation, physical therapy and a home exercise program. 
 
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 sacroiliac joint injection. Our 
reviewer says that the requested sacroiliac joint injection is not considered medically reasonable and necessary 
in this case. Our physician reviewer found sacroiliac joint (SI) joint injections are recommended as an option if 
the patient has failed at least 4-6 weeks of aggressive conservative therapy. Sacroiliac dysfunction is poorly 
defined, and the diagnosis is often difficult to make due to the presence of other low back pathology (including 
spinal stenosis and facet arthropathy). The diagnosis is also difficult to make as pain symptoms may depend on 
the region of the SI joint that is involved (anterior, posterior, and/or extra-articular ligaments). Pain may radiate 
into the buttock, groin and entire ipsilateral lower limb, although if pain is present above L5, it is not thought to be from the SI joint. The criteria for the use of SI joint blocks include that the patient has had and failed at least 
4-6 weeks of aggressive conservative therapy including, physical therapy (PT), home exercise and medication 
management. There should be evidence of a clinical picture that is suggestive of sacroiliac injury and/or 
disease. At least three positive exam findings of SI joint dysfunction should be present on physical exam such 
as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslen's test. The clinical value and 
effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have 
not been demonstrated in the peer-reviewed literature. In this case, there is no documentation on the physical 
examination of tenderness to the SI joint and no mention of SI provocative testing being completed with 
positive findings. The review has determined that the requested sacroiliac joint injection 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 a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection (27096).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve SPECT. You say that the service is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show that you may have a problem with the 
blood vessels in your heart. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms. 
 
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 SPECT. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found without documented symptoms 
suggestive of cardiac origin and no abnormal physical findings suggestive of such, specialized cardiac testing is 
not clinically useful. Therefore, without sufficient support made for this request, the SPECT test will be 
considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging, tomographic (SPECT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the enrollee has pain from other symptoms. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered for 
enrollees that meet certain criteria. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the enrollee has radiculopathy which does not meet the Medicare coverage indications for facet 
joint injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (J1437). 
 
You asked the Plan to pre-approve Monoferric. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Venofer (iron 
sucrose). 
 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 Monoferric. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug, Venofer. The reviewer found that there is no 
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. 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 monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric (J1437).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the form-fitting conductive garment rendered on August 17, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 form-fitting conductive garment rendered on August 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Endovenous ablation therapy (36476). 
 
You asked the Plan to pre-approve the Endovenous ablation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 Endovenous ablation therapy. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no objective 
(ABI) documentation of arterial perfusion considering the patients cardiovascular risk factors and there is 
nothing in the documentation to support the reasonableness or medical necessity of any procedures beyond 
what has already been 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 the Endovenous ablation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Endovenous ablation therapy (36476).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from ongoing skilled 
physical and occupational therapies. The Plan denied your request. The Plan says the criteria for admission to 
an SNF are not met in this case, and the requested care is not medically necessary. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee has received physical therapy 
(PT) and occupational therapy (OT). The enrollee was at a modified independent supervision level with 
functional mobility including gait to 1,100 feet. The enrollee was discharged from OT. 
 
Based on the documentation provided, the enrollee does not have any identifiable skilled nursing service needs 
which require the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provided medically necessary and reasonable treatment. The enrollee does not have any identifiable 
skilled therapy services needs which require the specialized skill, knowledge and judgement of a qualified 
therapist to safely and effectively provided medically necessary and reasonable treatment. The enrollee does 
not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services billed for November 12, 2021. 
 You asked the Plan to pay for the billed services. You say that there are no other claims for this date of service 
to bundle with. The Plan denied your request. The Plan says the service was not billed as required by coding 
regulations. 
 
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 00537 is anesthesia for cardiac electrophysiologic 
procedures including radiofrequency ablation. We find that CPT code 00537 is not supported. In this case, 
there are no medical records to show the services were provided, or that they were medically necessary. The 
Plan made multiple attempts to obtain additional information without success. 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 the anesthesia services billed for November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pre-approve dental services.

You asked the Plan to pre-approve dental services in advance. You say that these dental services are medically
necessary. The Plan denied your request. The Plan says dental services are not pre-approved per your Plan
contract. Maximus overturned the Plans denial stating these services are listed as covered. The Plan requested a
reopen and stated that Maximus did not follow the correct Plan language.

The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan contract is specific that dental services must be obtained first by an appropriate provider and after the
fact enrollees can submit a claim form and bill for possible reimbursement.

The Plan does not give prior authorization for dental services and is not required to by Medicare. Therefore, we
decided that the Plan does not have to pre-approve dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot inserts (L3000), provided on August 5, 2021. 
 
You asked the Plan to pay for the foot inserts. You say that the item was medically necessary. The Plan denied 
your request. The Plan says this item was obtained through a supplier not enrolled in Medicare. 
 
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. Therefore, we decided that the Plan does not have to pay for the foot inserts (L3000), provided on 
August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 4, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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. This 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 services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested service is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested service is considered an experimental/investigational procedure at this point 
in time. Two learned orthopedic groups have decided not to support the use of the requested service. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammography provided on August 27, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rule for 
payment has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 the diagnostic 
mammography provided on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography (92250), provided on February 2, 
2022. 
 
You asked the Plan to pay for the fundus photography. You say the service was medically necessary.      The 
Plan denied your request. The Plan says this is not a covered service.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the services listed in the Plans benefit chart; any service not specifically listed is 
excluded from coverage. 
 
We looked at the file and the Plan's rules. This service is not listed in the Plan's benefit chart, and therefore, is 
not covered. Based on this information, we decided that the Plan's rules for coverage of the fundus photography 
have not been met. Therefore, we decided that the Plan does not have to pay for the fundus photography 
(92250), provided on February 2, 2022.