Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) 
procedure. 
 
 
You asked the Plan to pre-approve a TAVR procedure. You say that the enrollee meets the medical necessity 
criteria for the requested procedure. The Plan denied your request. The Plan says the records do not show aortic 
stenosis, symptoms from the narrowing, or that the enrollee is involved in a clinical study. The Plan says that 
the requested procedure, and thus the related inpatient hospital admission, 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 a TAVR procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of mitral valve replacement and has no cardiovascular complaints. 
The documentation supports the presence of severe aortic regurgitation, but not aortic stenosis. Guidelines 
would not support the use of TAVR for this indication for a number of reasons, including the lack of aortic valve calcification in many such patients which can make anchoring of the new valve challenging. While there 
have been several promising clinical studies, there remain calls for continued clinical trials to assess the 
efficacy of TAVR for aortic regurgitation. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. 
 
 
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 TAVR procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a transcatheter aortic valve replacement (TAVR) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 22, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the 
documentation submitted consists of an appeal letter and duplicates of records previously reviewed. 
 
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 laboratory services provided on December 22, 2021 have been met. Therefore, we decided that the Plan does not have to pay for laboratory 
services provided on December 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that that the current appeal documentation does not 
include this required tumor typing and for this reason the requested therapy cannot be approved. The Plan 
denied your request. The Plan says that the current appeal documentation does not include this required tumor 
typing and for this reason the requested therapy cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary. Keytruda is not FDA-approved for the enrollees 
diagnosis without MSI or MMR testing. The use of Keytruda is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of Keytruda.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that you have multiple active comorbidities and would be expected to 
require close medical monitoring on an inpatient basis. Primary care provider specifically recommends intense 
therapy and you require therapy in more than one discipline. Thus, IRF criteria have been met and 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on October 1, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Maximus overturned the Plans denial for insufficient documentation in the file. The Plan requested a reopen
and provided additional information. The Plan states that this claim denied because the services were not
authorized by the enrollees Primary Care Physician. The Plan states this claim was billed as an office visit and
not urgent or emergent care.
The Plan is correct in this case. 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 in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue.
The claim was not billed as urgent or emergent care. Therefore, we decided that the Plan does not have to pay
for out of network physician services provided on October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says IRF is not medically 
necessary, and your needs can be met at a lower level of care such as skilled nursing facility (SNF), home 
health or outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81015 provided on July 9, 2022. 
 
You asked the Plan to pay for code 81015. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says payment for code 81015 is bundled into code 81000. 
 
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 81015 
is a column II code to column I code 81000 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 81015 provided on July 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiotherapy services. 
 
You asked the Plan to pre-approve the requested services. You say that the treatment will reduce the risk of any 
dose spillage. The Plan denied your request. The Plan says the intent of treatment is not curative and is not 
expected to lower risk of disease recurrence. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam radiotherapy is only covered under 
certain medical indications.  
 
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 services. Our physician 
reviewer found that the need for proton therapy is usually established with quantitative dosimetric information 
that shows a clinically meaningful reduction in radiation dose exposure of normal tissues. This was not 
provided for this case. Proton therapy is not supported by consensus or expert guidelines. The coverage criteria 
were not met. Therefore, the request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiotherapy services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol. 
 
You asked the Plan to pre-approve Ferumoxytol. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Ferumoxytol. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the plans required drugs 
would likely be less effective and/or likely have adverse effects for the 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 Ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 more stable and only requires short-term additional acute 
care services that can safely be administered at the current facility until more appropriate for a lower level of 
care. 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 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test identified with code 0012M 
provided on February 28, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are specifically not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0012M for CxBladder is not covered. 
 
We looked at the file and Medicare rules.Review of the file shows that the testing at issue is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of the Cxbladder detect test 
have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder detect test 
identified with code 0012M provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services (92004) provided on April 28, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
  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 ophthalmological services (92004) provided on 
April 28, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grafting of autologous soft tissue (CPT code 15769). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee is not experiencing a functional deficit. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the scalp defect is causing a functional deficit and is 
medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, 
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have 
not been met. Therefore, we decided that the Plan does not have to pre-approve grafting of autologous soft 
tissue (CPT code 15769).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from August 29, 2021, to 
September 2, 2021 billed with secondary diagnosis code R65.21. 
 
You asked the Plan to pay for the inpatient services billed with secondary diagnosis code R65.21. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code R65.21, defined as severe 
sepsis with septic shock. 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 the inpatient 
services billed with secondary diagnosis code R65.21. Our reviewer says that the documentation does not 
support the DRG billed. Our physician reviewer found the enrollee presented with fever, altered mental status, 
and fatigue. Emergency department exam documented vital signs of temp 37.9C, pulse 85, respiratory rate 28, 
blood pressure 122/87 and pulse oxygen saturation (SpO2) 97% on room air. The enrollee was described as in 
no acute distress, lungs were clear to auscultation bilaterally, no respiratory distress, and neurology status as 
alert and oriented at baseline. Laboratory test results included a white blood cell count of 17.0K, platelet count 
241,000, creatinine 1.68, and lactic acid 1.3. The enrollee's chest x-ray revealed interstitial coarsening appears 
chronic without definite evidence of focal pneumonia. The enrollee was diagnosed with septic shock with 
unclear source and admitted for further care. Treatment included IV fluids and IV antibiotics. History and 
Physical noted the enrollee became hypotensive and was placed on Levophed. The enrollee was also diagnosed 
with acute on chronic renal failure. The documentation does not support the secondary diagnosis of R65.21.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from August 29, 2021, to September 2, 2021 billed with secondary diagnosis 
code R65.21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee was recently hospitalized for urosepsis, and arterial blood gases (ABG) was consistent 
with acute-on-chronic hypercarbic respiratory failure. There is a diagnosis of chronic obstructive pulmonary 
disease (COPD), but records do not provide pulmonary function testing. The enrollee is severely obese. This 
enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. But Medicare does not cover a home ventilator when used as 
BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service February 
22, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for MDT services have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that all MDT services must include an identifier as 
additional claim documentation. 
 
 We looked at the file and Medicare rules. In this case, the claim for the services at issue was not submitted with 
a unique test identifier. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) 
billed for date of service February 22, 2022.