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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (CPT code 64624). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee has knee arthritis (painful inflammation and stiffness in the joints) but does 
not have mononeuritis or complex regional pain syndrome. 
 
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 physician reviewer 
found detailed documentation is not evident regarding any mononeuropathies or complex regional pain 
syndrome in the right knee. The LCD does not support this procedure for knee osteoarthritis. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 destruction by neurolytic agent, genicular nerve branches including imaging guidance, 
when performed (CPT code 64624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the appropriate location, 
and the enrollee is not too acute for LTAC services. The Plan denied your request. The Plan says the LTACH is 
not medically necessary, and the enrollee's needs are being met in the current inpatient hospital. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment (A9900, E0165, E0630, S9999) 
purchased on May 9, 2022 to May 17, 2022. 
 
You asked the Plan to pay for the medical equipment. You say that the items were medically necessary. The 
Plan denied your request. The Plan says these items were not purchased from a Medicare enrolled provider and 
are not eligible for coverage. 
 
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 providers at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for medical equipment (A9900, E0165, 
E0630, S9999) purchased on May 9, 2022 to May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51701 provided on June 8, 2022. 
 
You asked the Plan to pay for procedure code 51701. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 51701 is insertion of non-indwelling bladder catheter. 
 
We find that CPT code 51701 is not supported in the medical record. Specifically, the records do not describe 
how a urine specimen was obtained. Based on this information, we decided that Medicare rules for coverage of 
procedure code 51701 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 51701 provided on June 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ruxience (Q5119). 
 
You asked the Plan to pre-approve Ruxience. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not approved by the FDA for the 
enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Ruxience. Our reviewer says that the 
requested drug, Ruxience, is not medically necessary. Our physician reviewer found the requested use of 
Ruxience is not FDA-approved for the enrollees diagnoses. The reviewer also found the requested use is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that the requested drug 
is 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 Ruxience have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ruxience (Q5119).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan drops. 
 
You asked the Plan to pre-approve Zioptan drops. The Plan denied your request. The Plan says this medication 
does not fall under Part B coverage. 
 
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 Zioptan drops.  
 
Benefits for Zioptan drops 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: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) with daily 
ultrasonic guidance for placement of radiation therapy fields (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the requested IGRT is medically necessary. The Plan 
denied your request. The Plan says the requested service 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 IGRT. Our reviewer says that the 
requested IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested service is not considered the standard of care. Therefore, the reviewer found that the 
requested therapy is 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT) with daily ultrasonic guidance for placement of radiation 
therapy fields (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller (E2377), electronic
connection (E2311), and harness (E2313).
You asked the Plan to provide coverage for this request. You say that these accessories are medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller (E2377), electronic connection (E2311), and harness (E2313). The Maximus Physician Reviewer
determined the accessories to be reasonable. The Plan requested a reopen and argues it is documented in the
medical records that you have good function of the arm and hand. "The medical records provide abundant
support of the member's ability to utilize 3 separate power switches, and an integrated expandable controller
with accessories does not appear medically necessary." The Plan is correct in this case. The documentation
does not support that the expandable controller (E2377), electronic connection (E2311), and expandable
controller harness (E2313) were medically reasonable and necessary in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not
have to pre-approve an expandable controller (E2377), electronic connection (E2311), and harness (E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 30, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says the requested drug is prescribed for an off-label and not medically 
accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that you 
have a diagnosis of Raynaud's syndrome in the setting of neuropathy from carpal tunnel syndrome. The FDA 
has not stated that the requested drug is indicated for your condition. The Medicare-approved drug compendia 
do not contain a supportive citation for the use of the requested drug in your clinical situation. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an align-able system (L5910) for a below-knee prosthesis for the enrollee.
You asked the Plan to pay for this request. You say that the requested prosthetic is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the issue was not medical necessity but that the approved preparatory prosthesis already includes all the necessary components needed by the enrollee. No additional system is required nor is the provider allowed to bill this code separately.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must both request and report services correctly. In this case, code L5910 was requested for separately in error and this code and service are already included in the other codes approved by the Plan. Therefore, we decided that the Plan does not have to pay for an align-able system (L5910) for a below-knee prosthesis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need to wear these for your 
pain, swelling, varicosities, and hypertension. The Plan denied your request. The Plan says these compression 
stockings are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 4, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says there was no 
documented contact with the attending/primary care physician. Entering a name in box 17 of a 
claim form does not meet the documentation requirement of an actual referral to the licensed clinical social 
worker from the primary care or attending physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on January 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue exam by a pathologist (88305) provided on March 8, 
2022. 
 
You asked the Plan to pay for tissue exam by a pathologist. You say that this service was necessary and was 
reported correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. In addition, this service was not billed with a necessary modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. Medicare rules also say that payment is not made under the physician fee schedule for Technical 
Component (TC) services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings. In addition, TC services furnished by independent 
laboratories to hospital patients are not payable by the MAC. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of tissue exam by a pathologist have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Rather, the 
record supports that the sample was taken in a hospital setting. This also means that the technical component 
portion of this service is bundled into the payment to the hospital facility, and this service should be billed with 
modifier 26 to request payment for only the professional component. Therefore, we decided that the Plan does 
not have to pay for tissue exam by a pathologist (88305) provided on March 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service January 19, 
2022. You asked the Plan to pay for procedure code 64483. The Plan denied your request. The Plan says the claim 
was not coded correctly. 
 
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 64483 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 
procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64483 billed for date of service January 19, 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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 that the documentation does not support that the enrollee needs complex medical 
treatment in a LTACH. The enrollee has 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #20 for the enrollee.
You asked the Plan to pre-approve a crown. You say that a full coverage crown is the only option to save the enrollee's tooth. The Plan denied your request. The Plan says that the enrollee does not meet criteria for a crown. Maximus overturned the Plans denial. The Plan requested a reopen and provided dental x-rays for review.
Our Medical director looked at the case file and the reopen request. At issues is coverage for a crown for tooth #20. Our Medical director says that clinical documentation and imaging do not support that the enrollee has/had pathologic destruction of tooth #20 by caries or trauma, that involved three or more surfaces and at least one cusp. Our Medical director found that the enrollee's condition does not meet criteria for coverage of a crown.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #20 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health aide services (CPT code G0156). 
 
You asked the Plan to pre-approve the home health aide services. You say that the services are necessary. The 
Plan denied your request. The Plan says the clinical information did not indicate that the enrollee required 
skilled care at home. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
physician reviewer found the enrollee is medically stable without any recent hospitalizations or medical 
complications. The documentation does not support that the enrollee requires skilled 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the home health aide services (CPT code G0156).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on February 16, 2022. 
 
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says Original Medicare 
would be responsible for payment of all Medicare covered services related or unrelated to the members 
terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care 
from the effective date of election to the date of discharge or revocation. During the election, fee-for-service 
Medicare also covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a duplex scan 
provided on February 16, 2022.