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

 
We decided that the Plan does not have to pre-approve US IGRT (CPT code G6001) for twenty-five (25) 
fractions. 
 
You asked the Plan to pre-approve the US IGRT. You say that the US IGRT is medically necessary. The Plan 
denied your request. The Plan says the US IGRT is not medically necessary for superficial radiation therapy. 
 
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 US IGRT. 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 simulations (also requested in this case) or IGRT 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 US IGRT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve US IGRT (CPT code G6001) for twenty-five (25) fractions.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 speech therapy (ST) visits. 
 
You asked the Plan to pre-approve the ST visits. The Plan denied your request. The Plan says that the ST visits 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 ST visits. Our reviewer says that the 
10 ST visits are medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested therapy is generally accepted as a specific and effective therapy for the enrollee's dysphagia. A 
speech therapy evaluation dated July 28, 2022, indicated that the enrollee underwent a bedside swallow 
evaluation. Our reviewer found that the enrollee's swallowing was noted to be impaired, and they have a history 
of esophageal stricture requiring dilatation. Our physician reviewer also found that ST and the skills of a 
speech therapist would be appropriate to monitor the ability of the enrollee to safely swallow solids and liquids, 
as well as make appropriate recommendations regarding the type of fluid and consistency of food that is safe to 
swallow. 
 
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 ST visits have been met. Therefore, we decided that the Plan has to pre-
approve 10 speech therapy (ST) visits.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 there is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status. You can receive further 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an inpatient hospital stay provided from January 5, 
2022, to January 6, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient stay. You say that you should be billed for an 
inpatient stay copayment. The Plan denied your request. The Plan says that the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $175 copayment per day, days 1-5; $0 per day, days 6-90; 
$0 copay for additional days, after your $1,000 plan deductible, for in-network inpatient services. The medical 
records submitted show that your patient status during this stay was inpatient. This inpatient stay lasted 1 day, 
resulting in a copayment amount of $175. 
 
The Plan says you must pay a $295 copayment for an inpatient stay. Based on the Plan contract, however, you 
cannot be asked to pay more than a $175 copayment for this inpatient stay. Therefore, we decided that the Plan 
has to reduce the copayment for an inpatient hospital stay provided from January 5, 2022, to January 6, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a hypoglossal nerve stimulator.
You asked the Plan to provide coverage for this device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus administratively overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required records.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if a hypoglossal nerve stimulator is appropriate for coverage, a facility-based polysomnography must be performed within 24 months of the implantation consultation. The records show you had a home sleep study. This was not a facility-based study and does not meet the required criteria. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to provide coverage for a hypoglossal nerve stimulator.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 medical record does not indicate that you require services that the enrollee is not 
currently receiving but that would be available at the LTACH facility. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound (76642) provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this service was provided during 
your annual wellness visit and should have no copayment. The Plan denied your request. The Plan says this 
claim was processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $45 
copayment for basic imaging services (e.g., general x-rays or ultrasounds).  
 
You have been asked to pay a $45 copayment for the ultrasound. An ultrasound falls within the basic imaging 
services (e.g., general x-rays or ultrasounds) 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 the breast ultrasound (76642) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for code 62322.
You asked the Plan to provide coverage for the services requested. You say that these services were medically necessary for the enrollee. The Plan denied your request. The Plan says the issue was not the services requested but the codes applied to the service. Maximus overturned the Plans denial stating an interlaminar ESI was reasonable and necessary. The Plan requested a reopen and stated that while the Plan and Maximus agree that an interlaminar ESI is reasonable, the denial of 62322 was appropriate given the code does not represent the service that will be performed. The Plan also stated that LCD L33906 indicates codes 62320 and 62322 are not considered medically reasonable and necessary.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must request services correctly. In this case the code requested was not the intended service and therefore the prior authorization request was not coded appropriately. Therefore, we decided that the Plan does not have to provide coverage for code 62322.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 23, 2022 billed with 
codes 0031U, 0032U, 81227, 81230, 81231, 81291, 81328, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 23, 2022 billed with codes 0031U, 0032U, 81227, 81230, 81231, 81291, 81328, and 81355.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43281 billed for date of service July 8, 2021. 
 
You asked the Plan to pay for procedure code 43281. You say that this procedure code was medically 
necessary. The Plan denied your request. The Plan says payment for code 43281 is bundled into payment for 
code 43775. 
 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 43281 
is a column II code to column I code 43775. 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 43281 billed for date of service July 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan 
provided on May 2, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the copayment 
amount and would like the CT scan and ER charges combined. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
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 $250 
copayment for each covered diagnostic radiology service in the outpatient department of a network hospital or 
facility.  
 
You have been asked to pay a total of $224.40 which is less than the standard $250 copayment for a CT scan. 
A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 Computed Tomography (CT) 
scan provided on May 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop reader. 
 
You asked the Plan to pre-approve the implantable loop reader. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the implantable loop recorder is not medically necessary at this 
time. 
 
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 implantable loop reader. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this enrollee's 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 implantable loop 
reader have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantable 
loop reader.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 29, 2022, to 
February 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the physician admitted the enrollee to 
an inpatient status based on the information they had at the time of admission. The Plan denied your request. 
The Plan says that the enrollee could have safely been treated in an outpatient setting and/or urgent care 
facility. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 29, 2022, to February 1, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that an ILR is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of atrial 
fibrillation but there is no documentation to suggest a history of unexplained syncope or any other apparent 
indication for an ILR. The services are not reasonable or medically necessary for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot move on your own and you are getting 
weaker each day. The Plan denied your request. The Plan says that the stay is not medically necessary based on 
IRF 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the IRF admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 a microprocessor knee and advanced foot system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is not reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
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 services. Our physician 
reviewer found that the documentation provided does not support the use of the microprocessor knee and 
advanced foot ankle system. There is insufficient documentation supporting the enrollees potential K level 
given his current medical conditions. A clinical progress note dated June 30, 2022, indicated that the enrollee 
had to recently rely on a wheelchair and walker for mobility given post-surgical issues. At the same time, he is 
noted to be able to ambulate on his new prosthesis. The enrollee has a medical history of chronic obstructive 
pulmonary disease requiring supplemental oxygen. It is unclear what his current level of function and 
endurance is with regards to mobility. Lastly, the prosthetic evaluation does not indicate why a standard 
hydraulic knee would not meet the enrollees mobility needs. Therefore, the microprocessor knee and advanced 
foot ankle system 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 the requested service s have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee and advanced foot system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4253 and A4259 billed for date of service 
February 28, 2022, to March 1, 2022. 
 
You asked the Plan to pay for procedure codes A4253 and A4259. The Plan denied your request. The Plan says 
procedure codes A4253 and A4259 are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A4253 and A4259 have a status indicator of P on the Physician Fee Schedule. 
This means that procedure codes A4253 and A4259 are not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure codes A4253 and A4259 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes A4253 and A4259 billed for date of service 
February 28, 2022, to March 1, 2022.