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

 
We decided that the Plan does not have to pre-approve percutaneous angioplasty (PTA) and carotid artery 
stenting without distal embolic protection. 
 
You asked the Plan to pre-approve percutaneous angioplasty (PTA) and carotid artery stenting without distal 
embolic protection. You say that the requested percutaneous angioplasty (PTA) and carotid artery stenting 
without distal embolic protection is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested percutaneous angioplasty (PTA) and carotid artery stenting 
without distal embolic protection. 
 
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 percutaneous angioplasty (PTA) and 
carotid artery stenting without distal embolic protection. Our reviewer says that the enrollee does not meet 
criteria for the requested percutaneous angioplasty (PTA) and carotid artery stenting without distal embolic 
protection. Our physician reviewer found the documentation does not support the medical necessity of the 
treatment in question due to a lack of clarity for what appears to be a relatively complex anatomic and 
treatment decision making situation. The materials provided include 100s of pages of irrelevant and repetitive 
material and does not provide a cohesive rationale and treatment plan. An interval update on January 3, 2023, 
does mention carotid stenting but little more. There is a lack of clarity as to the rationale for treatment and what 
territories are being treated. It is documented that the enrollee recently presented with left-sided weakness but 
does not address how left-sided carotid stenting addresses that. There are references to carotid webs and distal 
left internal carotid artery stenosis in the records; however, this does not appear to be addressed at the time of 
carotid stenting planning. In summary, as there is a lack of clarity with respect to the treatment plan matched 
with what appears to be a complex situation, clearly different than a typical carotid bifurcation stenosis, it is not 
possible to overturn the health plans determination on the basis of medical necessity. Recommend 
resubmitting a new authorization request to the Plan with a concise enrollee evaluation and matching treatment 
rationale. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous angioplasty (PTA) and carotid artery stenting without distal 
embolic protection have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous angioplasty (PTA) and carotid artery stenting without distal embolic protection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve MRI. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plan's network) will not be covered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device coded as 22869 and 
22870. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that included with this letter is the 
clinical documentation which supports these clinical findings and medical necessity for the procedure. The Plan 
denied your request. The Plan says this procedure is considered investigational as more studies are needed to 
show Vertiflex is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion device coded as 22869 and 22870.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for eye surgery on August 26, 2022. 
 
You asked the Plan to waive the deductible for eye surgery. You say that you want to appeal the amount being 
charged. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient hospital services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time eye surgery was received on August 26, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for eye surgery on August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health stay provided 
from April 6, 2022, to May 6, 2022. 
 
You asked the Plan to waive the copayment for the inpatient mental health stay. You say that you do not agree 
with the copayment due to the lack of care the enrollee received. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $900 copayment per stay, for days 1 to 150, for each Medicare-covered mental health stay in a 
network hospital. 
 
 
 
 The enrollee has been asked to pay a $900 copayment for the inpatient mental health stay. This item/service 
falls within the inpatient mental health care benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the inpatient mental health stay provided from April 6, 2022, to May 6, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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 Keytruda is not Food and Drug 
Administration (FDA)-approved for the enrollee's diagnosis of ovarian cancer. Keytruda is indicated for the 
treatment of adult and pediatric patients with unresectable or metastatic, microsatellite instability-high (MSI-H) 
or mismatch repair deficient (dMMR) solid tumors, as determined by an FDA-approved test, that have 
progressed following prior treatment and who have no satisfactory alternative treatment options. Provided 
records do not document that this enrollee's tumor possesses microsatellite instability-high or mismatch repair 
deficient status. 
 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 Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for an out-of-network provider. 
 
You asked the Plan to pre-approve an in-network exception. You say that you need an in-network exception 
due to your obstructive sleep apnea. The Plan denied your request. The Plan says there are in-network 
providers available. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an in-network exception have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an in-network exception for an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amitriptyline. 
 
You asked the Plan to pre-approve Amitriptyline. The Plan denied your request. The Plan says the provider did 
not indicate if a monitoring plan is in place or if the benefit of this medication outweighs any potential risks. 
The Plan also says the provider did not give a diagnosis, and approval of Amitriptyline cannot be considered 
without a diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Amitriptyline. Our physician reviewer 
found the documentation does not support that Amitriptyline was medically reasonable or necessary for you. 
Our reviewer also found that the documentation does not support that Amitriptyline is safe and effective for 
you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Amitriptyline have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Amitriptyline.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of any joint of the upper 
extremity (73221). 
 
You asked the Plan to pre-approve an MRI of any joint of the upper extremity. The Plan denied your request. 
The Plan says that the criteria for coverage of the MRI was not met as no information was provided regarding 
treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of any joint of the upper 
extremity. Our reviewer says that an MRI of any joint of the upper extremity is medically reasonable and 
necessary for the enrollee. Our physician reviewer found the enrollee sustained an acute injury to their right 
shoulder on January 2, 2023. The enrollee has some weakness especially with external rotation and they are 
unable to lift their arm overhead. Our reviewer found that the physical exam revealed positive impingement 
tests and findings very suspicious for rotator cuff tear. Our physician reviewer found that based upon the 
enrollee's mechanism of injury and positive findings on physical exam for rotator cuff pathology, the requested 
MRI right shoulder should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of any joint of the upper extremity have been met. Therefore, we 
decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of any joint of the upper 
extremity (73221).  
 
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 the Vertiflex Superion interspinous spacer device 
(22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you are appealing the denial of the 
Vertiflex procedure. The Plan denied your request. The Plan says this device has not been shown to be safe and 
effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as 
safe and effective as the gold standard of decompression. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion interspinous spacer device (22869).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transports provided on August 31, 2022, and September 2, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transports. You say 
that the enrollee suffers from end stage renal disease rendering her unable to transport by wheelchair and 
required ambulance stretcher with constant monitoring by trained personnel. The Plan denied your request. The 
Plan says the ambulance transports were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 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 ambulance service, basic life support, 
non-emergency transports. Our reviewer says that the ambulance transport services were not medically 
necessary. Our physician reviewer found the transportation via ambulance from dialysis on August 31, 2022, to 
dialysis on September 2, 2022 and from dialysis on September 2, 2022 was not medically necessary. The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance service, basic life support, non-emergency transports have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transports provided on August 31, 2022, and September 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 20, 2021, to 
February 23, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code J96.01, described as acute 
respiratory failure. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support diagnosis 
code J96.01. Our physician reviewer found the enrollee was a 76-year-old male who presented to the 
emergency department with cough and shortness of breath. He was evaluated and found to have bilateral 
pneumonia and an exacerbation of chronic obstructive pulmonary disease. He was treated with intravenous 
fluids and nebulizer treatments. His condition stabilized and he was discharged home.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 20, 2021, to February 23, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network infusions provided from 
August 17, 2022, to August 24, 2022. 
 
You asked the Plan to waive the coinsurance for in-network infusions. You say that you were given a brand 
name drug rather than the generic, which is much cheaper. You had no control over this decision; therefore, 
you should not have to pay this copayment, it is too large on your income. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
You had infusions, resulting in a 20% coinsurance ($202.14 + $202.14 + $166.20 + $166.20 = $736.68) of 
$736.68. 
 
You have been asked to pay a $736.68 coinsurance for in-network infusions. This item/service falls within the 
Medicare Part B prescription drugs 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 coinsurance for in-network infusions provided from August 
17, 2022, to August 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on September 
7, 2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that this should be covered as a 
preventive service. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $275 copayment for outpatient diagnostic tests and therapeutic services and supplies (diagnostic 
radiology).  
 
 
  The enrollee has been asked to pay $175.88, which is less than the $275 copayment for the breast ultrasound. 
This item/service is an additional service in conjunction with the screening mammogram and falls within the 
outpatient diagnostic tests and therapeutic services and supplies (diagnostic radiology) benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for a breast ultrasound provided on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar-sacral orthosis (L0650). 
 
You asked the Plan to pre-approve the orthosis. You say that the enrollee will be needing a lumbar back brace 
and it is not part of the hospital stay. The Plan denied your request. The Plan says Payment for a spinal orthosis 
is included in the payment to a hospital or SNF if the orthosis is provided to a beneficiary prior to an inpatient 
hospital admission or Part A covered SNF stay. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the orthosis is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve the lumbar-sacral orthosis (L0650).