Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation retreatment (90868, 
90869, 90867). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 the services. Our physician reviewer 
found this enrollee clearly does not meet the clinical criteria for the use of Transcranial Magnetic Stimulation 
(TMS) therapy utilizing LCD (L36469) as the enrollee was administered Transcranial Magnetic Stimulation 
(TMS) by a nurse practitioner without the physician being in direct supervision or presence. 
 
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 transcranial magnetic stimulation retreatment (90868, 90869, 90867).
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 without extensive rehabilitation, the enrollee's 
caregivers agree that the enrollee's ability to live independently is jeopardized. The Plan denied your request. 
The Plan says when the enrollee is ready to leave the hospital the needed services can be provided safely in 
another setting such as skilled nursing facility (SNF) or home health.  
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. There is documentation that there is 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, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for procedure code 20936. The Plan denied your request. The Plan says procedure 
code 20936 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Monitor test (0013M) provided May 25, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you believe the evidence supporting the use 
of CxBladder Monitor as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the CxBladder panel remains unproven at this time. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder Monitor test (0013M) provided May 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the criteria for LTACH admission has not been met.  
 
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 LTACH services that are not already available at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). You asked the Plan to pre-approve the requested ILR procedure. You say that the ILR is medically necessary. 
The Plan denied your request. The Plan says the requested ILR does not meet the Medicare NCD coverage 
criteria.  
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that while the patient has a history of premature ventricular contractions 
(PVCs), there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or 
any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an ILR.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Cologuard test. 
 
You asked the Plan to pre-approve a repeat Cologuard test. You say that you badly need this test because you 
do not feel ok.  In addition, you believe that the test you had in December was a false positive. The Plan denied 
your request. The Plan says Medicare does not cover repeat Cologuard tests within three years. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard tests are only covered once every 
three years for qualifying beneficiaries. 
 In this case, you had a covered Cologuard test in December of 2022.  Therefore, you are not eligible for 
coverage of another Cologuard test until December of 2025 at the earliest, regardless of the reason. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a repeat Cologuard test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a repeat Cologuard test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on May 19, 2023. 
 
You asked the Plan to pay for home visit. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
May 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit (99214) provided on June 
22, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the office or other outpatient visit. You say that the provider is in-network, and 
you would like this claim to be processed accordingly. The Plan denied your request. The Plan says the 
enrollee has no OON benefits. The Plan also says that no medical necessity for an OON provider, such as an 
urgent or emergency situation, has been documented. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit (99214) 
provided on June 22, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2023 to June 17, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 21, 2023 to June 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 occupational therapy (OT) visits.  
 
You asked the Plan to pre-approve the therapy services. You say that you are not able to use full range of 
motion and struggle with daily tasks. The Plan denied your request. The Plan says your condition does not 
indicate that a continued skilled therapist is needed.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you were initially evaluated for OT on August 23, 2023, and noted to 
have shoulder pain and stiffness. However, you were also noted to have 0-1/10 pain and are independent with 
performing daily activities. Your strength is within functional limits. It is not clear why you require OT given 
that you are independent with daily activities and have minimal pain based on the documentation given. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 occupational therapy (OT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary.  The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested Botox. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Botox. Our reviewer says that the 
enrollee does not meet criteria for the requested Botox. Our physician reviewer found the Food and Drug 
Administration (FDA) indications for Botox include: Chronic Migraine, Overactive bladder and urinary 
incontinence due to a neurologic condition, Cervical dystonia, Spasticity, and Severe axillary hyperhidrosis. 
 
The review has determined that the requested use of Botox is not FDA-approved for the enrollees diagnosis. 
Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system. 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the SPRINT PNS system is 
medically necessary. The Plan denied your request. The Plan says current peer-reviewed data does not support 
PNS for fibromyalgia, phantom limb pain, diffuse polyneuropathy, nociceptive pain in trunk or lower back, or 
angina pectoris. 
 
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 SPRINT PNS system. Our reviewer 
says that the requested SPRINT PNS system is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the SPRINT PNS device is experimental for back pain. More research is 
needed 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 SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee on October 30, 2022.

You asked the Plan to pay for services rendered. You say that this claim should be paid. The Plan denied your request. The Plan says insufficient records were submitted to support the services billed. Maximus overturned the Plans denial. The Plan requested a reopen and showed that several requests were made for medical records were not responded to.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of this claim have been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided to the enrollee on October 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological and neuropsychological testing. 
 
You asked the Plan to pre-approve psychological and neuropsychological testing. You say that 15 hours of 
psychological and neuropsychological testing is medically necessary. The Plan denied your request. The Plan 
says 15 hours of psychological and neuropsychological testing is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that psychological and neuropsychological testing is 
covered when the criteria in the Medicare rules section of this decision 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 psychological and neuropsychological 
testing. Our reviewer says that the requested psychological and neuropsychological testing is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that this patient is being 
evaluated for pain. Based on the premise that this testing is intended to diagnose and characterize the 
neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain including 
detection of neurologic disease based on quantitative assessment of neurocognitive abilities, differential 
diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central 
nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system 
disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or management 
strategies among individuals with neuropsychiatric disorders, this patient does not meet the criteria for 
neuropsychological testing in that this testing is not required for pain management and is therefore not 
considered to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological and neuropsychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve psychological and neuropsychological testing.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on March 12, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that the medical records support the billing of 
code 99284. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99284. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 procedure code 99284. Our reviewer says that the medical 
records do not support the billing of code 99284. Our reviewer found the medical records do not support an 
appropriate history or exam to justify billing code 99284. The medical records do not support a moderate level 
of medical decision making to justify billing code 99284.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 provided on March 12, 2023.