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

 
We decided that the Plan does not have to pay for radiological services provided on September 15, 2022. 
 You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says these codes are bundled into payment of another 
procedure code. 
 
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 74176-26-59, 70490-26-59, 71250-26-59, and 70450-26-59 are 
column II codes to column I code 78812; however, 74176-26-59, 70490-26-59, 71250-26-59, and 70450-26-59 
were billed with a modifier.  
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the medical record does not support that 
codes 74176-26-59, 70490-26-59, 71250-26-59, and 70450-26-59  were performed as a distinct separate 
service, independent of procedure code 78812. Therefore, it is not appropriate to use modifier 59. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiology services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for radiological services provided on September 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for ambulance transport services provided to the enrollee on December 10, 2021.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says as the enrollee was under hospice election, this claim should be submitted to Original Medicare first for review. Maximus overturned the Plans denial for insufficient in for information in the case file to confirm the enrollee's hospice status on the date of service. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The Plan has demonstrated that the enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for to pay for ambulance transport services provided to the enrollee on December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sildenafil Citrate. 
 
You asked the Plan to pre-approve Sildenafil Citrate. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Sildenafil Citrate.  
 
Benefits for Sildenafil Citrate 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and have 
provided medical records for review. The Plan denied your request. The Plan says the records do not show that 
the enrollee failed BiPap management. Additionally, the prescription for the requested noninvasive ventilator is 
for use exclusively in BiPap mode. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic hypoxic and hypercapnic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee was successfully treated with BiPAP. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services prior to their surgery. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint injections, two levels. 
 
You asked the Plan to pre-approve injections. You say that you need these injections. You say that you have 
rheumatoid arthritis in your neck region and the pain that comes along with it. The Plan denied your request. 
The Plan says the requested injections are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients when certain criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the 
requested injections are not medically necessary. Our physician reviewer found the provided documentation 
does not discuss a need for lumbar facet blocks. Therefore, the reviewer found that the requested injections are 
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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve lumbar facet joint injections, two levels.
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 it is medically necessary acute care 
services for the enrollee. The Plan denied your request. The Plan says the enrollee doesnt meet all the 
requirements. 
 
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 the enrollee is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64635, 64636). 
 
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the records do not show physical 
exam evidence of facet joint pain. The cause of back pain is not well-defined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64635, 64636).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Timolol maleate solution. 
 
You asked the Plan to pre-approve Timolol maleate. You say that the enrollee has done well on timolol 
maleate. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 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 Timolol maleate solution.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the service requested is not supported based on the records. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for sepsis, cellulitis, and anemia and was discharged to skilled nursing on 4/17/23. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 31, 2022.
You asked the Plan to pay for procedure code 76641. You say that the records support the procedure was performed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab and pembrolizumab. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has platinum-resistant 
ovarian cancer. The requested bevacizumab and pembrolizumab are not approved by the Food and Drug 
Administration (FDA) for this diagnosis. The use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. There is only a phase two non-randomized 
trial and no phase three data. The requested drugs are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bevacizumab and pembrolizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right foot orthotic (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are necessary to prevent 
surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease, and they do not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve the right foot 
orthotic (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the cleaning (D1110) and the fluoride treatment (D1206) provided on September 6, 2022.
You asked the Plan to pay for the dental services. You say that you had oral cancer which resulted in an extremely dry mouth and a jaw infection. The Plan denied your request. The Plan says that the fluoride treatment (D1206) is not a covered benefit and the frequency limitations for the periodic oral evaluation (D0120) and the cleaning (D1110) have been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 periodic oral evaluation (D0120) and the cleaning (D1110) was exhausted on date of service May 18, 2022. The fluoride treatment (D1206) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the cleaning (D1110) and the fluoride treatment (D1206) provided on September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic functional luminal imaging probe 
(EndoFLIP). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says while EndoFlip may offer improved assessment of esophageal distensibility and is a 
promising novel technique, its use in lieu of conventional manometry is not standard of care in achalasia 
diagnosis, and as such 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has symptomatic type 1 achalasia based on endoscopic, radiographic, and manometry data from less than a year ago. She is not considered a surgical candidate at this time due to her ongoing need 
for plavix. That the enrollee current provider proposes to reproduce all 2022 studies, with the addition of 
Endoflip. Whereas Endoflip is commonly considered pre-operative to surgical correction of achalasia, the study 
at this time is neither necessary nor appropriate since surgery for the enrollee is to be postponed by at least 6-
months.  
 
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 an endoscopic functional luminal imaging probe (EndoFLIP).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that you need this surgery and have been waiting over a 
year for it. The Plan denied your request. The Plan says you do not meet medical necessity for the requested 
medication with the clinical documents provided. The Plan also says there are no notes that you have achalasia. 
 
The Plan follows Medicare rules. Medicare rules say that Botulinum toxin products are covered when 
medically necessary for treatment of spasticity, blepharospasm, achalasia, anal fissures, hyperhidrosis, 
sialorrhea, urinary incontinence, and headaches/migraines. 
 
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 you do 
not meet the coverage criteria for Botox. Our physician reviewer found the record indicates that you have 
esophageal dysmotility and specifically excludes achalasia as a diagnosis. The noted diagnosis is not one for 
which coverage is available under the applicable rules. Our reviewer found that the elements of the coverage 
criteria are not satisfied. Our physician reviewer also found that the requested service is not recommended. 
 
 
 
 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 Botox (J0585).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement (D4355), retainer crowns (D6740), 
pontics (D6245), extractions (D7210/D7140), and additional periapical imaging (D0230), provided on July 27, 
2022, to August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been processed correctly. 
 
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 D0220/D0230 and D7210/D7140 was exhausted on August 15, 2022 D 4355,D6740 and D6245 are not covered benefits.Therefore, we decided that the Plan does not have to pay for a full mouth 
debridement (D4355), retainer crowns (D6740), pontics (D6245), extractions (D7210/D7140), and additional 
periapical imaging (D0230), provided on July 27, 2022, to August 29, 2022.