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

We decided that the Plan does not have to pay for surgery services provided to the enrollee on December 7, 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. The
Plan requested a reopen and stated that Maximus did not apply the correct coding criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for code 29823:
Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures, and code 29827:
Arthroscopy, shoulder, surgical; with rotator cuff repair. The Maximus Physician Reviewer determined that the
services at issue in this case were supported by the medical records. Our reviewer found that the procedure
notes the labral tears were debrided extensively down to a stable rim of the labrum in the anterior, superior, and
posterior regions of the joint. The undersurface of the rotator cuff was trimmed slightly in preparation for
repair. The subacromial space was decompressed and a soft tissue decompression and release of the
coracoacromial ligament was performed. This supports that extensive debridement was performed on 3 or more
discrete structures. Therefore, the records do support that code 29823 was rendered in this case.
The Plan requested a reopen stating the coding submitted was not supported. The medical records show the
enrollee was a 69-year-old man with a left shoulder rotator cuff tear, left shoulder labral tear, left shoulder
biceps tenosynovitis, and left shoulder impingement syndrome. On December 7, 2021, the enrollee underwent
left shoulder arthroscopic rotator cuff repair, left shoulder arthroscopic extensive labral tear debridement, left
shoulder arthroscopic biceps tenodesis, and left shoulder arthroscopic subacromial decompression. It is
documented that an acromioplasty was not performed. The documentation does not support that code 29826
(Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with
coracoacromial ligament (ie, arch) release, when performed) was rendered in this case, as an acromioplasty was
not performed.
We looked at this coder'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 pay for surgery services provided to the enrollee on December 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services. The Plan denied 
your request. The Plan says you do not meet criteria for SNF care, your needs can be met with services such as, 
in a long- term care setting with part-time skilled services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy sessions for the enrollee. 
 
You asked the Plan to pre-approve the additional sessions. You say that this is medically necessary. The Plan 
denied your request. The Plan says it cannot be said that these sessions were medically reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional sessions. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. The requested sessions are not medically reasonable or necessary. Our physician reviewer 
found that in this case, the enrollee has previously been treated with outpatient therapies and should be 
independent with a home exercise program. There is no documentation of a recent injury or decline in function. 
The additional therapy services are not an appropriate duration and frequency for treatment of the enrollees 
medical condition and therefore are 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 additional sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy sessions for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testing of the F5 gene (FVL) and the F2 gene. 
 
You asked the Plan to pre-approve testing of the F5 gene (FVL) and the F2 gene. You say that the requested 
testing is medically necessary for embolism and thrombosis of superficial veins of left lower extremity. The 
Plan denied your request. The Plan says the request is not medically necessary because the enrollee is not 
pregnant. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing for FVL and F2 is considered 
investigational unless the enrollee is pregnant, or the testing will change clinical management 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 testing of the F5 gene (FVL) and the F2 
gene. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee is not pregnant. FVL and/or F2 genetic testing will not change clinical management of the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of testing of the F5 gene (FVL) and the F2 gene have not been met. Therefore, we 
decided that the Plan does not have to pre-approve testing of the F5 gene (FVL) and the F2 gene.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar decompression. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested procedure is to be 
performed with interspinous process distraction devices at two spinal levels. These devices are experimental for 
use in spine surgery. Also, the diagnosis of symptomatic lumbar stenosis is not clearly made in the medical 
records. The services are 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 lumbar decompression.
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 the enrollee may benefit from 
bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep 
as an outpatient. Failure to completely correct PaCO2 over a short time frame while the enrollee is acutely ill 
does not constitute BiPAP failure by Medicare criteria. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia. 
 
You asked the Plan to pre-approve Kerendia. You say that this medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says Kerendia is not covered for the enrollee's condition by 
their Medicare Part B 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 Kerendia.  
 
Benefits for Kerendia 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. You say that denying this medication would put the enrollee at risk 
for cardiovascular complications. The Plan denied your request. The Plan says Xarelto is a self-administered 
drug, and does not fall under 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 Xarelto.  
 
Benefits for Xarelto 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR.) 
 
You asked the Plan to pre-approve TAVR. You say that the enrollee has congestive heart failure, long term 
anti-coagulant, a pacemaker, stage 3 kidney disease, and a severely dilated atrium. The Plan denied your 
request. The Plan says the records do not show aortic stenosis, symptoms from narrowing, or that the 
beneficiary is enrolled in a clinical study. The Plan says that the requested procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TAVR is covered for 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 TAVR. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
severe aortic regurgitation. This is not an enumerated condition in the coverage criteria. The record does not 
indicate that the enrollee is enrolled in a clinical trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transcatheter aortic valve replacement (TAVR.)
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the documentation fails to indicate that the member requires the intensity and 
specialization of services offered in rehabilitation, medical practitioner monitoring or treatment at least three 
times a week, specialized skills or equipment, or rehabilitation nursing care 24 hours daily. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for congestive heart failure. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended split-night sleep study. 
 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. Medicare rules say that a sleep study is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
obstructive sleep apnea (OSA) made in 2016. According to the clinical notes, she was doing well with a 
continuous positive airway pressure (CPAP) device until the device was recalled. She stopped using it and 
symptoms recurred. The diagnosis of OSA does not appear to be in question, and there is no issue with 
effectiveness of CPAP. The sleep study is therefore not reaosnable 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 an attended split-night sleep study.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality (J3590). 
 
You asked the Plan to pre-approve Emgality. The Plan denied your request. The Plan says Emgality is on the 
self-administered drug list and is excluded from coverage under Part B. 
 
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 Emgality (J3590).  
 
Benefits for Emgality 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. 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 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 Tecentriq. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Atezolizumab in not FDA approved for 
progression of disease after prior immunotherapy for metastatic non-small cell lung cancer as monotherapy or 
in combination with bevacizumab. Use is not supported by major drug compendia or the medical literature. The 
service is 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to a SNF would allow the enrollee more 
time to work with therapies at a lower endurance facility. The Plan denied your request. The Plan says the 
Medicare criteria for SNF admission were not met and the enrollee can receive the services they need at home 
with home health care services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311) for a power 
wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that the equipment is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when 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 expandable controller. Our reviewer 
says that this controller is not medically necessary. Our physician reviewer found the enrollee has adequate 
upper extremity strength and function to operate the wheelchair's power options with their own switches.  
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2311) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thoracoscopy and mediastinoscopy (procedure codes 32666, 
39402) provided to the enrollee on June 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported in the records submitted. 
 
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 the denied codes is: 
 
 
 CPT 32666: 
 
Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral 
 
CPT 39402: 
 
Mediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 32666, the 
operative report describes a wedge resection and a segmentectomy in the right upper lobe and the right middle 
lobe. In this case, the more comprehensive procedure would be reported, as services were performed in same 
anatomical area. In a segmentectomy, a larger section is taken than a wedge section. Therefore, modifier -59 
cannot be verified. In terms of CPT 34902, the operative report does not describe a mediastinoscope inserted in 
the space in the chest between the lungs, and tissue taken for biopsy. 
 
We looked at this coder'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 pay for thoracoscopy and mediastinoscopy (procedure codes 32666, 39402) provided to the enrollee on 
June 27, 2022.