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

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and each additional 
vertebral body (64629). 
 
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. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the magnetic resonance imaging (MRI) shows facet degenerative joint disease (DJD) and 
spondylolisthesis. The cause of back pain is not clear.  
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 the thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628) and each additional vertebral body (64629).
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 December 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the codes should not be 
included in the dialysis rate. 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 December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (64493) and second level (64494) to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the injections. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. The Plan states there are providers 
in-network that can provide the services. 
 
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 injections. Our physician reviewer 
found the enrollee has multiple probable pain generators. Facet joint injections are indicated when other 
sources of pain have been ruled out or treated. Therefore, at this time, the request does not meet the LCD 
criteria. Furthermore, the requested provider is out-of-network. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint 
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 
(64493) and second level (64494) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of anemia 
in the setting of myelodysplastic syndrome with ringed sideroblasts. The records do not show he has received 
two units of packed red blood cells in an eight-week period. The Food and Drug Administration (FDA) has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
Reblozyl is 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 pre-approve Reblozyl.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on March 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider type is 
not payable for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgery services 
provided on March 23, 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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. 
 
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 clinical documentation shows that enrollee requires ongoing physical therapy 
(PT) but does not show that the enrollee would tolerate or require an intensive rehabilitation regimen in an IRF 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral occipital nerve block procedure (64450, 
64405). 
 
You asked the Plan to pre-approve the Bilateral Occipital Nerve Block Procedure. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that more than two anatomic sites injected at any one 
session will be denied. 
 
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 bilateral occipital nerve block 
procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer found 4 
anatomical sites at/in one session is requested. 
 
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 bilateral occipital nerve block procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the bilateral occipital nerve block procedure (64450, 
64405).
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 member currently meets the criteria for an IRF 
admission. The Plan denied your request. The Plan says the member does not meet the requirements for an IRF 
admission. 
 
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 members nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that the member would meet criteria for admission to an acute inpatient rehabilitation facility. 
The member can receive further services 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: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for lab services (87640) provided to the enrollee on October 8, 2021.
You asked the Plan to pay for these services. 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 insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that code 87640 under Claim A was denied as bundled against code 87641 under Claim B. The Plan noted however Claim B was not added to the original case file for review and were submitted with the reopen request.
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, code 87640 could not be paid as billed due to its bundled relationship with code 87641 previously paid on Claim B.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87640) provided to the enrollee on October 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on April 15, 2022, under code 99310.
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 noted that review of the claim's history shows the provider submitted a claim which included, 9931025 on July 06, 2022, and the code was paid on July 21, 2022. The maximum number of units allowed per day for this code is 1. Medicare guidelines shows an "MUE Adjudication Indicator" (MAI) for each code. An MAI of "1" indicates that the edit is a claim line MUE. An MAI of "2" or "3" indicates that the edit is a date of service MUE. Therefore, based on the Medicare guidelines this claim denied correctly.
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 the MUE of the code billed does not allow the code to be billed twice in this setting by the same provider.
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on April 15, 2022, under code 99310.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
November 10, 2021, to November 11, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record does not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two 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 pay for the acute inpatient hospital care provided from November 10, 2021, to  
November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072, A4556, A4557, A4649, A9279, 
S1015, and S8301 billed for date of service August 26, 2022. 
 
You asked the Plan to pay for procedure codes 99072, A4556, A4557, A4649, A9279, S1015, and S8301. You 
say that asdfasd The Plan denied your request. The Plan says the billed codes are not 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We also find that procedure codes A9279, S1015, and S8301, 
have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes A9279, S1015, 
and S8301, are not valid for Medicare purposes. Lastly, we find that procedure codes A4556, A4557, and 
A4649, have a Status Indicator of P on the Physician Fee Schedule. This means that procedure codes A4556, 
A4557, and A4649, are not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 99072, A4556, A4557, A4649, A9279, S1015, and S8301 have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
. Based on this information, we decided that Medicare rules for coverage of procedure codes 99072, A4556, 
A4557, A4649, A9279, S1015, and S8301 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99072, A4556, A4557, A4649, A9279, S1015, and S8301 billed for date of 
service August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from December 2, 2021, to December 4, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial stating the admission was medically necessary. The Plan requested a reopen and stated that without medical records from the prior admission, it could not be determined if the second admission was billed correctly. The previous discharge dated was November 29, 2021. The Plan states the issue was not medical necessity but the appropriate billing of a second and separate admission.
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. The records provided are insufficient to show the second admission was not a result of premature discharge from the first admission on November 29, 2021. Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from December 2, 2021, to December 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS heart failure monitoring device 
(33289). 
 
You asked the Plan to pre-approve a CardioMEMS heart failure monitoring device. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the CardioMEMS device is considered 
experimental. 
 
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 CardioMEMS heart failure 
monitoring device. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the CardioMEMS device is considered experimental. 
 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 CardioMEMS heart failure monitoring device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a CardioMEMS heart failure monitoring device (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this procedure is helpful. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. No compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
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 January 5, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. 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 January 
5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Indirect Decompression System 
for implantation of Superion interspinous spacers (ISS) (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion Indirect Decompression System for implantation of 
Superion interspinous spacers. You say that the service is medically necessary. The Plan denied your request. 
The Plan says the vertiflex device is considered experimental. 
 
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 Vertiflex Superion Indirect 
Decompression System for implantation of Superion interspinous spacers. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
vertiflex device is considered experimental.  
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 Vertiflex Superion Indirect Decompression System for implantation of 
Superion interspinous spacers have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion Indirect Decompression System for implantation of Superion interspinous 
spacers (ISS) (22869).