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

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001), also 
known as US-IGRT. 
 
You asked the Plan to pre-approve radiation therapy. You say that you need the procedure to be covered under 
your plan since the procedure helps you to not feel pain, no bleeding, infection, cutting, and a quick recovery. 
The Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. There is not enough evidence that this type of radiation therapy guidance is needed or effective for 
your skin cancer. Therefore, it not considered standard of care. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found certainly, using ultrasound on a daily basis is not unreasonable to offer but not 
necessary. The device itself is FDA approved for use with ultrasound though that in and of itself does not mean 
that daily imaging is necessary but simply that the device was designed to incorporate this functionality. 
Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has not been 
established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general) is not necessary. The decision is unfavorable as 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 radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasound guided radiation therapy (G6001), also known as US-IGRT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapy services from an out-of-network (OON) 
provider at the in-network benefit level. 
 
You asked the Plan to pre-approve the OON therapy services at the in-network benefit level. You say that the 
phone numbers of 2 of the in-network providers you were referred to did not work. You say that the third 
network provider you were referred to did not provide the services you are requesting. The Plan denied your 
request. The Plan says medically necessary care is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that they will pay for medically necessary services provided out-of-network, but that the costs for 
these covered services may be higher.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services at the in-network benefit level. There is no network deficiency or evidence 
that medical necessary care can only be provided out-of-network. Therefore, we decided that the Plan does not 
have to pre-approve therapy services from an out-of-network (OON) provider at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a destruction by neurolytic agent, paravertebral facet 
joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and a 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 
lumbar or sacral, each additional facet joint (64636). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that you are in severe pain and 
have muscle spasms. You are unable to turn at night. The Plan denied your request. The Plan says you do not 
meet criteria for approval of the requested procedure. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have chronic low back pain. You have had multiple trigger point 
injections, a laminectomy in 2021, and had an RFA in 2018. There has not been repeat diagnostic MBBs 
performed. Since it has been more than 2 years since the last RFA, 2 sets of repeat diagnostic MBBs are 
required. Therefore, at this time, the request does not meet criteria for approval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and a destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or 
sacral, each additional facet joint (64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy with imaging 
guidance (IG-IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that IMRT for node-negative early-stage non-melanoma skin cancers is not standard of care. IMRT can 
be considered medically necessary (even for non-standard indications) when justified by quantitative dose 
measures- when the dose-volume exposure of critical structures in unacceptable without IMRT. These 
differences should result in a clinically meaningful benefit. This is not shown in the case records. IMRT or 
IGRT would be furnished in accordance with accepted standards 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity-modulated radiation therapy with imaging guidance (IG-IMRT).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the bone density study (77080) provided on November 10, 2022. 
 
You asked the Plan to pay for the bone density study. You say that the cost of the bone density test should have 
been covered in full. You also say that you would never have gone if you had known it was not covered. The 
Plan denied your request. The Plan says that the original determination will be upheld due to the provider 
billing these services with type of bill 130. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the bone density study by a contract provider. The file does not show that the Plan 
provided notice that the bone density study would not be covered. Specifically, you saw a participating 
provider for a service that could be covered under some instances (that is, bone density tests are covered, and 
more than once every 24 months if medically necessary). Under Medicare rules, this means the bone density 
study is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the bone density 
study (77080) provided on November 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481 and 87482, provided 
June 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the service was necessary to assist the 
enrollee's physician to diagnose the enrollee's chronic urinary tract infection condition and create an informed 
treatment protocol. The Plan denied your request. The Plan says procedure codes 87481 and 87482 are not 
approved for coverage using the diagnosis N39.0 Urinary tract infection, site not specified. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a urinary tract infection. Infectious agent detection by nucleic acid (DNA or RNA); candida species, amplified probe technique (87481) and infectious agent detection by nucleic 
acid (DNA or RNA); Candida species, quantification (87482) was performed. These tests are approved for 
consideration when used for vaginitis or onychomycosis, not UTI. Also, using both procedure codes is 
excessive as the 87481 also includes amplification. Also, it was not clear why standard urine bacterial/fungal 
cultures were not performed. Therefore, based on the provided documentation, the above testing will be 
considered 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87481 and 87482, provided June 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin and Paclitaxel. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin and Paclitaxel. You say that these drugs are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Keytruda, Carboplatin and Paclitaxel. 
Our reviewer says that this drug combination is not medically necessary. Our physician reviewer found the use 
of this chemotherapy combination is not supported by the Medicare-approved compendia for the enrollee's 
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 Keytruda, Carboplatin and Paclitaxel have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Keytruda, Carboplatin and Paclitaxel.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for peripheral vascular disease and had revision of a right leg 
below the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do 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 you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation the enrollee is participating in a clinical trial or study. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term peer-reviewed literature that shows this requested 
allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Globus Kinex (bioactive bone void filler), in this case, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (A9900, 
E2300, E2311, E2313, E2331, E2377, K0108). 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says it is not medically necessary to control the three requested power 
options through the joystick/drive interface. 
 
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 additional accessories. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has adequate upper body strength to manage multiple power switches. 
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (A9900, E2300, E2311, E2313, 
E2331, E2377, K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97530, 97110 and 97140) provided on 
April 19, 2022. 
 
You asked the Plan to pay for therapy services. You say that this claim has been filled out correctly. The Plan 
denied your request. The Plan says the taxonomy code reported for this provider does not match the taxonomy 
code on file with the Centers for Medicare and Medicaid Services for the provider with this NPI. 
 
The Plan must follow Medicare rules. Medicare rules say that the rendering provider's National Provider 
Identifier (NPI) should be entered in the lower unshaded portion of item 24J.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the taxonomy code reported with this NPI does 
not match the taxonomy code on file with the National Plan and Provider Enumeration System (NPPES) for 
this provider. Therefore, we decided that the Plan does not have to pay for therapy services (97530, 97110 and 
97140) provided on April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission for an amputation. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that surgery is medically necessary. 
The Plan denied your request. The Plan says the surgical excision of the nodule is done to relieve symptoms 
and prevent progression of the disease. The tumor must be excised into a long margin of normal tissue to 
prevent local recurrence. Your records do not show a severe infection in your foot, ankle or leg, a severe injury, 
a cancerous tumor, or a complication from a joint replacement. Because the procedure requested is not 
medically necessary, the inpatient hospital admission is also 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 pre-approve inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission is 
met in this case. Our physician reviewer found the review indicates that you have plantar facial fibromatosis 
(Ledderhose disease). You have bilateral sided forefoot pain and have had previous surgery for plantar 
fibromas. The surgical excision of the nodule is done to relieve symptoms and prevent progression of the 
disease. The tumor must be excised into along with a margin of normal tissue to prevent local recurrence. The 
records do not show amputation is within standard of care for this condition. The review has determined that 
the record does not show that at the time of inpatient admission the admitting physician reasonably expected 
that your necessary hospital care (including earlier ED and/or observation care) would span two midnights. The 
requested amputation is not medically necessary and reasonable and does not meet criteria for an inpatient 
hospital admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital admission for an amputation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for anesthesia and unauthorized dental services provided on June 10, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you were provided with unauthorized dental services that are not
covered under your benefit. Maximus overturned the Plans denial because they were provided by an in-network
provider. The Plan requested a reopen and stated that Maximus did not apply the correct dental criteria.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Enrollees received a
plan contract with specific instructions regarding supplemental dental benefits. You did not have prior
authorization for these dental benefits. Their costs, if covered, exceed the maximum benefit offered by the
Plan. The services provided are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pay for anesthesia and unauthorized dental services provided on June 10, 2022.