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

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) (77370). 
 
You asked the Plan to pre-approve SBRT. You say that the enrollee has a diagnosis of secondary malignant 
neoplasm of liver and intrahepatic bile duct. The enrollee's hepatic function appears to also support his 
candidacy for SBRT. The Plan denied your request. The Plan says there is no data for this approach, and it 
would be considered not generally accepted. Other forms of therapy would be proper and more in keeping with 
known 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for metastatic disease, SBRT is generally only indicated for enrollees with oligometastatic 
disease of for those undergoing palliation after prior radiation. Oligometastases are defined as a state of 
metastatic disease with metastases few in number and extent. For this enrollee, the plan is to treat a liver 
metastasis from pancreatic cancer; other sites of metastases are well-controlled on systemic therapy. While 
SBRT for oligoprogression is an emerging approach it is not standard of care at this time and would not meet 
ASTRO model policy criteria. The most recent American Society of Radiation Oncology (ASTRO) model 
SBRT coverage policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, 
and kidney lesions is medically necessary when the enrollees performance status justifies aggressive 
treatment, and for those whose tumor burden can be completely targeted with acceptable risks. The decision is 
unfavorable for SBRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT) (77370).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup. You say that you received a letter that core buildup was 
approved for a different dental provider, but when you went to a participating provider it was denied. The 
Plan denied your request. The Plan says this service is not covered by your dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
posterior lumbar decompression and fusion and will need inpatient admission after surgery. The Plan denied 
your request. The Plan says there is no documentation provided to support the expectation the enrollee will 
require a greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a posterior lumbar decompression and fusion. 
The record does not document that the treating physician has a reasonable expectation of a length of stay 
spanning 2 or more 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomy (37766). 
 
You asked the Plan to pre-approve the stab phlebectomy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are > than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
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 stab phlebectomy. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the provided documentation did 
not clearly describe the patient having fully tried weight loss, daily exercise, or periodic leg raising to consider 
them having fully exhausted conservative treatment options. Also, although the incompetent veins were greater 
than 4 mm in diameter, there was evidence of untreated reflux of the saphenous veins.  
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 stab phlebectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomy (37766).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you cannot be on your own without rehab and are 
currently bedridden. The Plan denied your request. The Plan says that the SNF services requested do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic agent injection (64447) provided on 
September 6, 2022. 
 
You asked the Plan to pay for the anesthetic agent injection (64447). You say that the claim should be 
processed for payment. The Plan denied your request. The Plan says procedure code 64447 is included in 
procedure code 01230. 
 
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 64447 is a column II code to column I code 01230; however, 64447 
was 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 the anesthetic agent injection (64447). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report includes insufficient documentation to confirm an anesthetic agent injection was given. In this 
case, modifier 59 is not supported as the documentation does not support this procedure was separate from the 
anesthesia service as well as requested by the surgeon. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the anesthetic agent injection (64447) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthetic agent injection (64447) provided on September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 clinical documentation shows that the enrollee requires ongoing physical, occupational and speech 
therapy and an intensive rehabilitation program. 
 
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 inpatient rehabilitation facility (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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac computed tomography (CT) coronary calcium 
scoring. 
 
You asked the Plan to pre-approve CT coronary calcium scoring. You say that this test can more accurately 
quantify the calcium plaques in the arteries of your heart and evaluate your current treatment effectiveness. The 
Plan denied your request. The Plan says this screening service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that screening CT coronary calcium scoring is not 
covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CT coronary calcium scoring have not been met. Therefore, we decided that the Plan does not have 
to pre-approve cardiac computed tomography (CT) coronary calcium scoring.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that you are requesting reconsideration for the denial 
of a PET scan. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records provided for review indicate 
that the enrollee had previously undergone neuropsychological testing that was suggestive of Alzheimer's 
disease only. There is no mention in the records of a suspicion of frontotemporal dementia or that the enrollee 
meets diagnostic criteria for both conditions. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D5932 and D7953). 
 
You asked the Plan to pre-approve the dental services (D5932 and D7953). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the services 
are not covered benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental services (D5932 and D7953).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for code 76641 billed for date of service August 29, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that per the Medicare MUE Practitioner Services sheet effective July 1, 2022, code 76641 has an MUE value of 1. The MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022, update. As the date of service in question is August 29, 2022, the new MUE value of 1 would apply.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed based on the MUE value of the code on the date of service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 76641 billed for date of service August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on November 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the records show that the enrollee has 
multiple medical conditions, including lumbar radiculopathy with chronic low back pain. His treatment 
included oxycodone and gabapentin, as well as medication management of long-term (current) drug therapy. In 
addition, the record shows a definitive urine drug testing (UDT) panel for multiple drug classes was performed 
but does not show screening test results which are positive or inconsistent with prescription medications, 
dosing schedules, or history and expected results. The testing was therefore 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 pay for the definitive drug testing rendered on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test provided on October 18, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test provided on October 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that procedure code 99223 was not bundled with 
any other procedure code performed on the same date of service. You say that the medical records should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says payment for 
code 99223 is bundled into payment for code 32555. 
 
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 99223 
is a column II code to column I code 32555. 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 99223 billed for date of service November 18, 
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically necessary. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that clear that you were medically stable, and that it was reasonable to expect that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF, at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) with acute and chronic respiratory failure with hypoxia, as well as congestive heart 
failure. The case file does not contain documentation of trial and failure of bi-level positive airway pressure 
(BiPAP) therapy with backup rate and average volume-assured pressure support (AVAPS). The documentation 
is insufficient to support that a home ventilator (E0466) is medically reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.