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

 
We decided that the Plan does not have to pay for the services provided on May 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until August 18, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT) 
(G6001). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is not enough medical evidence to show that this type of radiation 
treatment is effective to treat your skin cancer. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound guided radiation therapy (US-IGRT) (G6001).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for needle electromyography, two extremities with or without related 
paraspinal areas (CPT code 95861), continuous intraoperative neurophysiology monitoring, from outside the 
operating  room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes 
(list in addition to primary procedure)) (G0453), somatosensory testing (95938) and central motor evoked 
potential study (transcranial motor stimulation); in upper and lower limbs (95939) provided on April 14, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the diagnosis codes on the claim do not support the billed procedure codes. 
 
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 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 found the medical records 
provided for review do support that the billed services were performed during the episode of care under review. 
The records contained adequate documentation and description of said services to support their provision. As 
these measurements were monitored in real time, the use of G0453 is also well supported. This would meet 
criteria for coverage. 
 
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 has to pay 
for needle electromyography, two extremities with or without related paraspinal areas (CPT code 95861), 
continuous intraoperative neurophysiology monitoring, from outside the operating  room (remote or nearby), 
per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary 
procedure)) (G0453), somatosensory testing (95938) and central motor evoked potential study (transcranial 
motor stimulation); in upper and lower limbs (95939) provided on April 14, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Palonosetron. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found opdivo, like gemzar are low 
emetogenic regimens and unless failure of zofran, kytril are not medically 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 Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided from August 2, 2021, through August 31, 2021.
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you were informed to pay $2,393.84 and you would be reimbursed $1,518.42. You say that there is nothing that says this should not be covered and you need the money back. 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 20% coinsurance for Medicare-covered therapeutic radiology services.
You have been asked to pay a 20% coinsurance for the radiation therapy services. This item/service falls within the Medicare-covered therapeutic radiology services 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 coinsurance for the radiation therapy services provided from August 2, 2021, through August 31, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the therapeutic radiology treatment planning; complex provided on 
August 4, 2022. 
 
You asked the Plan to pay for the therapeutic radiology treatment planning services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says that the services rendered are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the therapeutic radiology treatment planning 
services. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has new right breast cancer. Intensity-
modulated radiation therapy (IMRT) is supported for enrollees with breast cancer who are status post 
lumpectomy. In addition, it was already approved for the opposite breast cancer. Therefore, the enrollee had a 
diagnosis/condition that met criteria for the services rendered. 
 
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 therapeutic radiology treatment planning services have been met. Therefore, 
we decided that the Plan has to pay for the therapeutic radiology treatment planning; complex provided on 
August 4, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller upgrade, harness upgrade, power 
seat elevation system, functional reach/transfer package, electronic connection between the wheelchair 
controller and two or more power seating system motors, and bag hooks. 
 
You asked the Plan to pre-approve expandable controller upgrade, harness upgrade, power seat elevation 
system, functional reach/transfer package, electronic connection between the wheelchair controller and two or 
more power seating system motors, and bag hooks. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that upgraded electronics are covered when 
there is a medical need to control power options through the joystick. The documentation does not support a 
medical need to control the power options through the joystick. The power options can be controlled using their 
own switches. The requested power seat elevation system is specifically not covered. The reach system and bag 
hooks do not service a medical purpose. These items are specifically not covered.  
 
Based on this information, we decided that Medicare rules for coverage of expandable controller upgrade, 
harness upgrade, power seat elevation system, functional reach/transfer package, electronic connection between 
the wheelchair controller and two or more power seating system motors, and bag hooks have not been met. 
Therefore, we decided that the Plan does not have to pre-approve expandable controller upgrade, harness 
upgrade, power seat elevation system, functional reach/transfer package, electronic connection between the 
wheelchair controller and two or more power seating system motors, and bag hooks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous infusion, for therapy, prophylaxis, or 
diagnosis associated with inpatient hospital admission (96365). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the clinical value and effectiveness of ketamine infusion therapy in the 
setting of CRPS Type I and cervical dystonia have not been demonstrated in the peer-reviewed literature. The 
requested hospital stay is not covered because it is associated with a procedure that is not covered. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for intravenous infusion with inpatient hospital 
care is met in this case. Our physician reviewer found based on the medical records provided, there is no detail 
indicating that the admitting physician reasonably expected that the enrollee's necessary hospital care would 
span two midnights. In addition, the Medicare-approved major drug compendia designate ketamine infusion 
therapy for chronic pain as not recommended, the given test, or treatment is not useful, and should be avoided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve intravenous infusion, for therapy, prophylaxis, or diagnosis associated with 
inpatient hospital admission (96365).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied
your request. The Plan says that the enrollee's needs can be met at a lower level of care such as a skilled
nursing facility (SNF).
Maximus overturned the Plans denial stating IRF care would be necessary. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The medical
records indicate the enrollee would not be expected to be able to actively participate in and to benefit from an
intensive rehabilitation therapy program. Therefore, we decided that the Plan does not have to pre-approve
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lower 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that based upon the limited records submitted 
the MRI of lumbar spine has been already approved by the plan but the MRI of the lower extremity, side not 
specified, should not be approved as medically 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) scan of the lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D7140) on August 23, 2022. 
 
You asked the Plan to pay for the dental services (D7140). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the requested 
item or service (D7140) 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 August 23, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services (D7140) on August 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are not getting better. You say you 
can't walk or stand, and you need the care. The Plan denied your request. The Plan says criteria for admission 
to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that you have the need for complex medical 
treatment in an LTACH. You do not require services at the LTACH that are not available at the acute care 
hospital or the skilled nursing facility. You have improved medically and can receive further care at the current 
acute care hospital or a lower level of care when deemed appropriate. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T and C1825). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the Barostim Neo device in the setting of 
congestive heart failure have not been demonstrated in the peer-reviewed literature. The Plan states there 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of Barostim Neo in patient management. 
 
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 an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable 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 Barostim Neo device (0266T and C1825).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health physical therapy services provided from 
June 9, 2021, through August 4, 2021. 
 
You asked the Plan to pay for home health services. You say that the service should be paid. The Plan denied 
your request. The Plan says the provider did not submit documentation to support that skilled services were 
provided to the member on any of the billed dates during the dates of service covered on these claims or to 
validate that the care rendered is related to the primary diagnosis. The Plan states the physical therapy 
reevaluation dated May 28, 2021, submitted in the prior episode of care is missing the comparison of the 
current evaluation functional measurements to the prior evaluation functional measurements. The Plan states 
this visit note contained status update and narrative which demonstrated measurements of current functional 
status. The Plan states this visit note did not contain successive comparison or the therapists determination of 
the effectiveness of therapy or lack thereof. The Plan states physical therapy visits billed will be non-billable 
until a valid 30-day reassessment is completed. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found the documentation does 
not indicate that the physical therapist made a successive comparison of the enrollee's functional status and 
improvement in a 30-day period. The documentation indicates that at the time of the 30-day evaluation there 
was no successive comparison or effectiveness of therapy or lack thereof. We looked at this physician's review, 
the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home 
health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
physical therapy services provided from June 9, 2021, through August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facet joint injection provided on May 18, 2022. 
 
You asked the Plan to pay for the facet joint injection. The Plan denied your request. The Plan says the facet 
joint injection does not meet the Medicare LCD coverage criteria. 
 
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 pay for the facet joint injection. Our reviewer says 
that the facet joint injection was not medically necessary. Our physician reviewer found that the enrollee had 
diagnostic medial branch blocks, but there is no quantification of the degree and duration of pain relief.  
There is no imaging provided. There was no evidence of physical therapy. There are no musculoskeletal exams 
provided. Prior notes indicate minimal relief from prior injections. A lack of documentation precludes meeting 
the Medicare LCD criteria.  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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for a facet joint injection provided on May 18, 2022.