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

 
We decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT) represented by 
code 77373. 
 
You asked the Plan to pre-approve SBRT. You say that proton beam therapy is medically appropriate, and the 
Plan's denial is based on outdated guidance. The Plan denied your request. The Plan says SBRT is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The requested service (77373 Stereotactic Body Radiation Therapy) is not a proton therapy 
code, per se. Your argument with regard to the benefits of proton therapy over conventional radiation therapy does not adequately address the health plans coverage denial in this case (as the requested service is not a 
proton therapy code). Additionally, your argument does not adequately address the issue of Stereotactic Body 
Radiation Therapy versus Intensity Modulated Radiation Therapy which the Plan indicates would be favored in 
this case. That is why the denial of code 77373 is appropriate here. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiotherapy (SBRT) represented by code 77373.  
 
Please note- this decision is limited to a determination on coverage for SBRT, as that was the specific code that 
was requested.  The authorization request was not for proton beam therapy as it appears you may be asking for 
in your appeal letter.  The Plan has not issued a denial for proton beam therapy, so Maximus has no jurisdiction 
to make a determination on that specific service.  If you wish to request proton beam therapy for the patient, 
please contact the Plan directly.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) at an 
out-of-network outpatient hospital provided on November 16, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) at an out-of-network 
outpatient hospital. You say that the cost of the test should have been fully covered. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $275 copayment for a magnetic resonance imaging (MRI) at an out-of-network 
outpatient hospital. This item/service falls within the outpatient diagnostic test benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a magnetic resonance imaging (MRI) at an out-of-network outpatient 
hospital provided on November 16, 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 it is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not require an intensive level of therapy requiring 
physician oversight. 
 
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 
was admitted for weakness, dyspnea, ventricular tachycardia, congestive heart failure, and coronary artery 
disease. Medical problems are stable. There are no complex nursing or rehabilitation needs. There is not a 
reasonable expectation that this patient 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 it is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet all of the requirements. 
 
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 
was admitted for rib fractures and a hemothorax. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that this 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 waive the copayment for an IRF stay provided from December 14, 
2022, to January 3, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you should not be charged two 
separate copayments because you were never discharged home and stayed in the same hospital. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $365 
copayment each day for days 1 to 5 and $0 copayment for days 1 to 6 for each inpatient hospital stay.  
 
 You have been asked to pay $1,825 copayment each day for days 1 to 5 and $0 copayment for days 1 to 6 for 
an IRF stay ($365 per day x 5 days = $1,825). This item/service falls within the inpatient hospital stay benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an IRF stay provided from December 14, 2022, 
to January 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
14, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 14, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that that the diagnostic criteria for both 
Alzheimer's disease and frontotemporal dementia has 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit. 
 You asked the Plan to pay for an emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an emergency department visit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the device. You say that the enrollee urgently needs this procedure due to 
worsening heart failure. The Plan denied your request. The Plan says this should only be approved for patients 
enrolled in a clinical trial. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289 and C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5968) and an all lower extremity prostheses, foot, flexible keel 
(L5972). 
 
You asked the Plan to pre-approve the requested prosthetic leg components. You say that this should be 
approved. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that the need for specific prosthetic components may be 
documented based on the enrollee's functional level. IT is also noted that replacement of prosthetics is covered 
only when 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 the requested prosthetic leg 
components. Our reviewer says that the documentation does not support that the requested items are medically 
necessary. Our physician reviewer found an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968) and an all lower extremity prostheses, foot, flexible keel (L5972) 
exceeds the enrollee's functional needs. The requested item is not medically necessary per Medicare guidelines 
as there is no evidence of irreparable damage or wear or extenuating factors that require a replacement of the 
patient's current prosthetic parts which are still under warranty. Additionally, the physician documentation does 
not support that the patient is unable to meet his functional needs with his current foot.  
 
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 requested prosthetic leg components have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, multiaxial ankle with 
swing phase active dorsiflexion feature (L5968) and an all lower extremity prostheses, foot, flexible keel 
(L5972).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing and/or skilled therapy services. 
The enrollee is medically stable and can receive further rehabilitation services 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that you need a PET scan. The Plan denied your 
request. The Plan says a PET scan is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the requested PET scan is not medically necessary. Our physician reviewer found that it is not noted that you 
have either AD or FTD. The requirements for coverage of this service would not be met as you do not meet the 
criteria for both AD and FTD. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 18, 2022. 
 You asked the Plan to pay for ambulance services. You say that the claim needs to be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that this procedure will give the 
patient a higher quality of life. The Plan denied your request. The Plan says the CardioMEMS procedure is 
considered experimental/investigational for the patient's condition. 
 
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 CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve the service. You say that the ablation is medically necessary. The Plan 
denied your request. The Plan says the request cannot be approved because it is a service that research has not 
proven to be helpful. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an investigational experimental procedure due to the wide variation in 
efficacy reported in the literature.  therefore, the request 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance 
(64625).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on December 21, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. 
 
We looked at the file and Medicare rules. The record shows that the enrollee had the sacroiliac joint injection 
(27096) performed on December 21, 2022. The MFSDB shows that the postoperative period for this code is the 
day of surgery/procedure. The enrollee received the Bupivacaine (J3490) injection on December 21, 2022, 
which is the same day the initial procedure was rendered. Therefore, we decided that the Plan does not have to 
pay for procedure code J3490 provided on December 21, 2022.