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

 
We decided that the Plan does not have to pre-approve peripheral artery revascularization of the lower 
extremities, lower extremity revascularization with angioplasty, arthrectomy, and stent placement (32730, 
37231, 37228, 37229, 37221, 37220, 37226, 37227, 37224 and 37225). 
 
You asked the Plan to pre-approve peripheral artery revascularization of the lower extremities, lower extremity 
revascularization with angioplasty, arthrectomy, and stent placement. You say that this is medically necessary. 
The Plan denied your request. The Plan says the records do not show that the enrollee has had a trial of 
conservative management including antiplatelet therapy, home exercise, or tobacco cessation, or that the 
enrollee has stenosis of 70% or greater in the proximal vessels. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous transluminal angioplasty can be 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 pre-approve peripheral artery revascularization of 
the lower extremities, lower extremity revascularization with angioplasty, arthrectomy, and stent placement. 
Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found the 
description of the patient's symptoms does not sufficiently support that the patients walking limitation is due to 
claudication. There does not appear to be an effort to treat conservatively or evaluate for other etiologies for leg 
pain. There is documentation of normal pulses, and the duplex does not demonstrate any significant 
lesions. The ankle brachial indexes are near normal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral artery revascularization of the lower extremities, lower extremity 
revascularization with angioplasty, arthrectomy, and stent placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve peripheral artery revascularization of the lower extremities, lower 
extremity revascularization with angioplasty, arthrectomy, and stent placement (32730, 37231, 37228, 37229, 
37221, 37220, 37226, 37227, 37224 and 37225).
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 enrollee would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says an implanted loop 
recorder is not medically necessary.  
 
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 there is no documentation provided to suggest a history of 
unexplained syncope, cryptogenic stroke, or any other apparent indication for an insertable cardiac monitor 
(ICM). Also, there is insufficient documentation to support the medical necessity for insertion of an ICM in the 
enrollee's 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 implanted loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 provided on December 7, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 87481 is Infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, the laboratory results do not 
include Candida. Based on this information, we decided that Medicare rules for coverage of procedure code 
87481 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87481 
provided on December 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed tomography, thorax, low dose for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve a Computed tomography scan. You say that the enrollee does not meet the 
criteria for this service. The Plan denied your request. The Plan says Computed tomography, thorax, low dose 
for lung cancer screening (71271). 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a Computed tomography scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not 
fulfill the CMS criteria as having a personal 20 pack year smoking history. 
 
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 Computed tomography scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed tomography, thorax, low dose for lung cancer screening 
(71271).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 80307 provided on July 21, 2023. 
 
You asked the Plan to pay for procedure code 80307. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not provided enough evidence to support the denial of 
payment for procedure code 80307 based on Medicare criteria. The Plan denied payment for procedure code 
80307 because a code from the same range, 80305, was paid for on another claim for the same date of service. 
However, the Plan has not provided any evidence showing that procedure code 80305 was paid for on another 
claim. Therefore, we decided that the Plan has to pay for procedure code 80307 provided on July 21, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for August 28, 2023. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only standalone codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) and physician or other qualified health care professional attendance and 
supervision of hyperbaric oxygen therapy (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that without the therapy, the wound 
would rapidly deteriorate and risk loss of limb or life of the enrollee. You also say the healing potential is based 
upon the increase in perfusion and will aid in healing of the wounds. The Plan denied your request. The Plan 
says Medicare guidelines say that HBO therapy is not covered for chronic peripheral vascular disease. The 
records show the enrollee has chronic peripheral vascular disease and is scheduled for vascular surgery 
evaluation. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee at this junction does not require HBO but rather 
revascularization and then could be a candidate for HBO therapy. There would likely be no benefit of HBO 
without the adequate blood flow to the limb. Hence, at this time, no indication for HBO. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 
(G0277) and physician or other qualified health care professional attendance and supervision of hyperbaric 
oxygen therapy (99183).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on September 19, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the 
physician is not a network provider with the Plan also determined that these services are not urgent or 
emergent, nor were they approved in advance 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The Plan had network providers available who could provide the items/services at issue in this appeal. (Please 
note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) 
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 physical therapy 
services provided on September 19, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee has right knee pain and 
has tried a Synvisc injection on September 28, 2023, with minimal relief. You say that the enrollee has also 
tried a steroid injection to their right knee on August 15, 2023, with 50% pain relief for two weeks. The Plan 
denied your request. The Plan says the genicular nerve block is 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered an experimental procedure. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 16, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on November 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Butrans patch. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Butrans patch.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a non-invasive ventilator (E0466).

You asked the Plan to provide coverage for this device. You say that at the time of the appeal, this ventilator
was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not
met. Maximus partially overturned the Plans denial and approved 3 months for transition to a different type of
device. The Plan requested a reopen and stated that Maximus did not apply the correct coverage in this case.

The Plan is correct in this case. 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 chronic obstructive pulmonary disease (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 continued use of a noninvasive ventilator. Our
physician reviewer found you have severe COPD and apparently have had a home ventilator since a
hospitalization in 2022. However, this is no documentation of an Arterial Blood Gas done while stable to
document chronic CO2 retention. Without this documentation, there is no indication you would not benefit
from the use of a bilevel positive airway pressure (BiPAP) device with average volume-assured pressure
support (AVAPS) during sleep. The records do not show that this has been tried and failed as an outpatient.
Medicare does not cover a home ventilator when used at settings that can be provided with a BiPAP. Therefore,
we decided that the Plan does not have to provide coverage for this device to include non-coverage for
transition to a new device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing radiographic images (D0274) provided on 
October 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not ask for the service to be done. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 4, 2023. Therefore, 
we decided that the Plan does not have to pay for the bitewing radiographic images (D0274) provided on 
October 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650, 95972, C1897). 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because the records do not show the 
functional and pain relief response to the trial. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators can be 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 pre-approve a spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found the records in this case 
do not document trial and failure of psychological therapy. The records also do not clearly document the 
patient has no active substance abuse issues as required by the LCD. Records show plans for a urine drug 
screen but no results. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator (63650, 95972, C1897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2025, V2203, V2781, V2744, V2750, 
V2782) received on August 18, 2023, from an out-of-network provider.  
You asked the Plan to pay for the eyeglasses. You say that you want the Plan to pay for the services. The Plan 
denied your request. The Plan says the provider is out-of-network and there was no authorization. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses (V2025, V2203, V2781, V2744, V2750, V2782) received on August 18, 2023, from an out-of-
network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint PNS system (64555). 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item 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 Sprint PNS system. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this item 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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Sprint PNS system (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390). 
 You asked the Plan to pre-approve the oxygen concentrator. You say that your health is at risk and buying one 
on your own is far too expensive. The Plan denied your request. The Plan says your oxygen levels in your 
blood were not low enough to meet the requirements for oxygen coverage detailed in the Local Coverage 
Determination (LCD) titled, LCD - Oxygen and Oxygen Equipment (L33797). 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen concentrator. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found you do not meet the standard 
guidelines for  home oxygen therapy and do not have documented hypoxemia. Hence, no indication for home 
oxygen given the documentation and data provided. 
 
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 oxygen concentrator. have not been met.  Therefore, we decided that the 
Plan does not have to pre-approve an oxygen concentrator (E1390).