Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the use of Tobramycin. 
 
You asked the Plan to pre-approve the medication. You say that the use of Tobramycin is medically necessary 
for the enrollee's condition.  The Plan denied your request. The Plan says that the drug is not covered under 
Part B, but is approved for Part D. 
 
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 the medication. Our reviewer says that 
the enrollee does meet criteria. Our physician reviewer found the inhaled Tobramycin is routinely used in 
enrollees with Pseudomonas infections and is common practice.  The enrollee has a Pseudomonal infection and 
therefore has indication for treatment with Inhaled Tobramycin.  Therefore, it is indicated for treatment of this 
enrollee. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve the use of Tobramycin.  
 
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 an application of a modality to 1 or more areas; infrared 
(97026) provided on August 10, 2023. 
 
You asked the Plan to pay for infrared therapy. You say that the chart notes attached can prove that the 
enrollee's treatments are medically necessary. The Plan denied your request. The Plan says infrared therapy is 
not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is considered not reasonable and 
necessary by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Specifically, infrared therapy is considered not reasonable and 
necessary and is excluded from coverage. Therefore, we decided that the Plan does not have to pay for an 
application of a modality to 1 or more areas; infrared (97026) provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350 x 3) provided 
on October 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider there would be no 
out-of-pocket costs. 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 Plan's 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 October 4, 2023. 
Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350 x 
3) provided on October 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 8, 2023, to May 12, 
2023, billed with procedure code 98940-AT. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied.  

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 8, 2023, and June 9, 2023. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the 
same date. Based on this information, we decided that the Medicare rules for the practitioner services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on May 8, 2023, to May 12, 2023, billed with procedure code 98940-AT.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service August 25, 
2023. 
 
You asked the Plan to pay for procedure code G0453. You say that these codes are add on codes and can be 
billed together with an applicable primary procedure code. You say that the claim should be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says payment for code G0453 is bundled into 
payment for code 95957. The Plan also says procedure codes 95861 and 95937 have been approved for 
payment. 
 
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 G0453 
is a column II code to column I code 95957. 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 G0453 billed for date of service August 25, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee has severe chronic pain syndrome and 
the patch seem to help monitor the enrollee's pain faster. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 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 Lidocaine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on March 17,
2023, to March 19, 2023, billed with evaluation and management (EM) code 99239.

You asked the Plan to pay for this claim as billed. 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 stated that
Maximus did not apply the correct billing criteria. The Plan states while they agree the service was provided,
the time spent was not recorded in the medical records which is a requirement for this code.

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. Code 99239 requires documentation of the
actual time spent with the enrollee in the record and must reflect 30 minutes of more spent for discharge
services.

The medial records provided do not show any times documented. Medicare rules for payment of this claim as
billed have been met. Therefore, we decided that the Plan does not have to pay for practitioner services
provided to the enrollee on March 17, 2023, to March 19, 2023, billed with evaluation and management (EM)
code 99239.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested PET scan is 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 PET scan. Our reviewer says that 
the requested PET scan is not medically necessary. Our physician reviewer found that the enrollee had a 
negative radionuclide stress test in 2018 and in 2020 had successful catheter ablation, with no recurrence of 
atrial fibrillation and with "much improved symptoms." There is no documentation that the electrocardiogram 
(ECG) shows an uninterpretable pattern. There is no evidence provided that would support the need for 
radionuclide stress testing at this time. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing in this patient'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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says they will continue to cover medically necessary acute 
and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of 
care (such as a skilled nursing facility), or until the clinical circumstances change such that LTACH may be 
reconsidered. 
 
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 appears to be improving with current treatment but is still somewhat unstable and should only require short-term additional acute care services that can safely be provided at the 
current facility until more stable and appropriate for transfer to a lower level of care. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH is not medically necessary as the patient is not yet stable for transfer and as it would not be 
clinically advantageous. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that you received this injection once and would like 
to see if it can be covered more often. The Plan denied your request. The Plan says a sacroiliac joint injection 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 injection. Our reviewer says that a 
sacroiliac joint injection is not medically necessary. Our physician reviewer found that there is no 
documentation of the degree of pain relief and duration of the pain relief from the last injection. Also, it is 
unclear if this is a repeat injection or switch to the left side. Therefore, with absent documentation the request is 
not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
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 the claim should be paid. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (80074, 86592) provided on July 27, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 the lab testing have been met. Provided 
records were limited to lab orders and results. No clinical records were submitted to support the services billed. 
Therefore, we decided that the Plan does not have to pay for lab testing (80074, 86592) provided on July 27, 
2023.
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 March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this code does not require authorization. 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 March 26, 2023, to April 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT scans. 
 
You asked the Plan to pre-approve the CT scans. You say that you are requesting the imaging to determine if 
you are in the early stage of disease. The Plan denied your request. The Plan says you do not meet the medical 
necessity criteria for the imaging services.  
 
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 the CT scans. Our reviewer says that 
the imaging services are not medically necessary. Our physician reviewer found given that you do not have 
symptoms and no risk factors other than family history, there is no indication for CT chest scans at this point.  
 
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 CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT scans (71250, 71270, 71260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abdominal aortic aneurysm screening provided on September 
27, 2023. 
 
You asked the Plan to pay for abdominal aortic aneurysm screening. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is a one-time screening 
ultrasound for people at risk. The Plan only covers this screening if you have certain risk factors and if you get 
a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) 
Section 422.101. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of abdominal aortic aneurysm screening have not been met. Therefore, we decided that the Plan does 
not have to pay for abdominal aortic aneurysm screening provided on September 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
September 2, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were discharged 
from the emergency room too soon, and you needed to return to the emergency room. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for emergency care.  
 
 
 You have been asked to pay a $110 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on September 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the enrollee has suffered from 
back pain for many years, and it makes it difficult for them to function. The Plan denied your request. The Plan 
says the radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, 
is considered investigational and therefore, not 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 the radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan and 
computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has already had one PET/CT scan for this condition. In the absence of 
a biopsy-proven cancer, a second PET/CT is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET/CT scan. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found the record indicates that the 
enrollee has enlarged tonsils and has already undergone one PET scan for this diagnosis that showed reactive 
inflammation likely secondary to acid reflux. The record does not document the presence of malignancy or 
further evidence suggestive of malignancy. 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan and computed tomography (CT) scan (78815).