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

 
We decided that the Plan does not have to pre-approve a tertiary level of care. 
 
You asked the Plan to pre-approve a tertiary level of care. You say that the records provided support that the 
services being requested are medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet the Tertiary Care guidelines. 
 
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 a tertiary level of care. Our reviewer 
says that a tertiary level of care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found port placement and further prescriptions for bladder cancer can be supplied by a 
network non-tertiary level of care provider. There are no unique issues that would warrant a tertiary 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 a tertiary level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a tertiary level of care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that a medically necessary high frequency ultrasound image 
is required prior to treatment delivery for two or three-dimensional evaluation of tumor volume providing an 
accurate assessment of the precise composition of the lesion(s), response to treatment, performance of adaptive 
radiotherapy; therefore, resulting in more accurate treatment in addition to accomplishing geometric accuracy 
of field placement for margin control. The Plan denied your request. The Plan says based on this information 
and criteria stated in the medical policy, IGRT is not medically reasonable or necessary, and is not approved. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to you for which the target lesion can be seen 
on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless 
deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer but 
not necessary. Therefore, to bill for daily simple simulations (also requested in this case) 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- citations below) is not necessary.  
Billing for daily IGRT or daily simulations (also requested in this case) would not be furnished in accordance 
with accepted standards of medical practice. The LCD above for proton therapy does not apply to 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT) (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician's services for an office visit 
provided on January 14, 2022. 
 
You asked the Plan to waive the copayment for physician's services. You say that you should have a zero 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 
a $15 copayment for physician/practitioner services, including doctors office visits, Out-of-Network for each 
Medicare-covered primary care doctor visit.  
 
You have been asked to pay a $15 copayment for physician's services. The physicians services falls within the 
physician/practitioner services, including doctors office visits benefit category Out-of-Network for each 
Medicare-covered primary care doctor visit. 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 physician's 
services for an office visit provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric level of care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee can be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric care. Our reviewer 
says that the enrollee does not meet the Medicare criteria for inpatient psychiatric care. Our physician reviewer 
found it is not expected that the enrollee will improve in a reasonable period of time as the enrollee does not 
have dangerous to self or others, and is not showing any auditory/visual hallucination or aggressive behaviors. It does not appear medically reasonable and necessary to have psychiatric care provided at the inpatient 
hospital level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for transurethral procedures (00910) provided 
on June 7, 2022. 
 
You asked the Plan to pay for the anesthesia for transurethral procedures (00910). You say that the claim 
denied for incorrect POS. You say that the documents should be reviewed, and the claim reprocessed for 
payment. The Plan denied your request. The Plan says the incorrect POS code was 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 00910 is anesthesia for transurethral procedures 
(including urethrocystoscopy); not otherwise specified. 
 
We find that CPT code 00910 is not supported in the medical record. Specifically, the records show the 
enrollee was an inpatient at the time of service, but the outpatient POS was billed. Based on this information, 
we decided that Medicare rules for coverage of the anesthesia for transurethral procedures (00910) have not 
been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for transurethral 
procedures (00910) provided on June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that the operative report supports the use of 
modifier 22. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service May 13, 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 the enrollee is not getting better or 
showing signs of improvement. You also say you would like the enrollee to be closer to home where you can 
visit more often. The Plan denied your request. The Plan says the LTACH services you are requesting do not 
meet the requirements for approval. 
 
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 appears to be more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until more appropriate 
for a lower level of care, however, weaning potential appears to be unlikely based on the provided 
documentation. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at 
this time and completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services were medically necessary. The Plan
denied your request. The Plan says the records do not show an ability to participate in an IRF therapy program.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. The
medical records provided do not show this enrollee has the physical or cognitive ability to participate in an IRF
therapy program at the time of the appeal.
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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve knee arthroscopy. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are 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 knee arthroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for knee stiffness and contracture of the knee. The 
enrollee presented with right knee pain rated at six out of 10. The symptoms began on September 5, 2022. The 
symptoms are sharp, dull, stabbing, throbbing, aching, and shooting. The problem is unchanged and made 
worse with twisting, moving, walking, standing, and lifting. There is swelling, stiffness, limping, clicking, 
locking, popping, and giving way. The exam of the right knee reveals evidence of crepitus with small effusion 
and medial joint line tenderness. Range of motion is zero to 100. Strength is four plus out of five in the 
quadriceps. 
 However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, there are no more advanced imaging 
studies that corroborate the pathology. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 4, 
2022.
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 at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct 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. The medical records provided do not show
you could be expected to actively participate in and to benefit from an intensive rehabilitation therapy program.
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at
least five days per week.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency care provided on February 21, 2022.
You asked the Plan to waive the copay for the emergency care. You say that you would like the copayment
waived because you have not been charged for emergency care before. The Plan denied your request. The Plan
says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100
copay for each emergency room visit.
You have been asked to pay a $100 copay for the emergency care. This item/service falls within the emergency
room visit 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 copay for the emergency care provided on February 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Synvisc, Durolane, and Gelsyn-3. The records do not show 
that the required drugs would be contraindicated or less effective; therefore, Trivisc is 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 Trivisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. The
patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation
therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of
therapy per day at least five days per week.
The medical records provided do not show the enrollee met these criteria at the time of the appeal. 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial 
surgery (95955) provided on January 29, 2021. 
 
You asked the Plan to pay for the EEG. You say that the service should be covered. The Plan denied your 
request. The Plan says the service was 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 pay for the EEG. Our reviewer says that the EEG is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
documentation does not indicate that at any time during the surgical procedure did the EEG show asymmetries or unilateral focal sharp activity. Therefore, the reviewer found that intraoperative EEG monitoring is not 
considered medically reasonable and necessary for monitoring cerebral function during anterior cervical 
decompression/fusion surgery. 
 
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 EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for the electroencephalogram (EEG) during non-intracranial surgery (95955) provided on January 29, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 71046, A4208, and A4649 billed for date 
of service May 16, 2022. 
 
You asked the Plan to pay for procedure code(s) 71046, A4208, and A4649. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. Medicare rules say that submitted claims in which the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 71046. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 71046. Code A4208 has a MUE value 
of zero. These items are bundled and not separately payable. Code A4649 has a status indicator of P. A status 
indicator of P means that payment for this service is always bundled into payment for other services not 
specified and no separate payment can be made. Based on this information, we decided that Medicare rules for 
coverage of procedure code 71046, A4208, and A4649 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 71046, A4208, and A4649 billed for date of service May 16, 2022.