Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and garments 
(E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that a successful demonstration 
was completed, and the enrollee had a reduction in swelling after a single treatment. You also say that the 
requested device and garments are medically necessary for the enrollee. The Plan denied your request. The 
Plan says the enrollee does not meet coverage for the requested device and garments. The records sent did not 
show that the enrollee has chest, trunk and/or abdominal or abdomen lymphedema. If the pneumatic 
compression device itself is not covered, then the related accessories are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and garments (E0656, E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; sacral nerve (transforaminal placement) including image guidance (CPT code 64561). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has tried and failed certain 
medications. The Plan denied your request. The Plan says the enrollee has other conventional therapies 
available to try to treat their condition, such as botox injections. 
 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 physician reviewer 
found the records do not show that the enrollee has the enrollee has tried and failed other first and second line 
treatments and may have neurogenic bladder. As such, the medical records provided do not meet the 
requirements listed in the NCD for Medicare coverage. 
 
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 percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal 
placement) including image guidance (CPT code 64561).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing coded 0013M provided on February 
22, 2022. 
 
You asked the Plan to pay for the Cxbladder testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0013M for CxBladder is not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the services rendered are specifically 
not covered. Based on this information, we decided that Medicare rules for coverage of the Cxbladder testing 
have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing coded 0013M provided on 
February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
procedure (Vertiflex) (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested procedure is necessary for 
the enrollee. The Plan denied your request. The Plan says the requested procedure 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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is considered experimental and therefore is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a posterior interspinous decompression spacer procedure (Vertiflex) (22869).
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 rules for IRF care have 
not been met however, skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (J9271). 
 
You asked the Plan to pre-approve Pembrolizumab. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the records do not show that the enrollee 
meets the criteria. 
 
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 Pembrolizumab. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Pembrolizumab is FDA approved as a single-agent treatment of metastatic non-small cell lung 
cancer in patients with tumors with PD-L1(programmed cell death ligand 1)  expression (TPS =1%), as 
determined by an approved test, and with disease progression on or following platinum-containing 
chemotherapy. Patients with EGFR (epidermal growth factor receptor) or ALK (anaplastic lymphoma kinase) 
genomic tumor aberrations should have disease progression (on approved EGFR- or ALK-directed therapy) 
prior to receiving pembrolizumab. Given the EGFR Exon 19 mutation EGFR directed therapy would be first 
line. 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 Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab (J9271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about your condition you do not meet the requirements for 
approval. 
 
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 you were admitted with small bowel obstruction and developed sepsis in the setting 
of perforation. The record indicates that you are improving but still require acute care services before 
transitioning to a lower level of care. The medical record does not indicate that you require services that you 
are not currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Belbuca 150MCG film. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Belbuca 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 Belbuca 150MCG film.  
 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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a lumbar MRI. We decided that the Plan does not have to pre-
approve a cervical and thoracic MRI.  
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI) services.. You say that the enrollee has 
new symptoms of back pain, tingling, and numbness. The Plan says that the services are not medically 
necessary. 
 
We decided that the Plan has to pre-approve a lumbar MRI.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 requested services. Our physician 
reviewer found that the enrollee has a long history of low back pain for which she has received 2 steroid 
injections in 2022. While she has no red flags, her persistence of symptoms qualifies her for MRI of the lumbar 
spine.   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 been met. Therefore, we decided that the Plan has to 
pre-approve a lumbar MRI.  
 
We also decided that the Plan does not have to pre-approve a cervical and thoracic MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 cervical and thoracic MRI. Our 
physician reviewer found that the records show no neurology exam or red flag to mandate an MRI of the 
cervical or thoracic spine. There are no plain films of the spine. There is no documentation of a bone scan to 
look for bone metastases, although it would be unlikely for a patient with stage I breast cancer to have same 
diagnosed in 2020. The medical necessity of MRI of the cervical and thoracic spine has not been established in 
the records 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 a cervical and thoracic MRI have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cervical and thoracic MRI. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on March 28, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that this should be paid. The Plan denied your request. 
The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Initial Hospital Care and Subsequent Hospital 
Care codes are per diem services and may be reported only once per day by the same physician or physicians 
of the same specialty from the same group practice. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital care have not been met. Specifically, the file shows that the Plan paid this service for 
the same date of service, by a provider with the same specialty in the same billing group. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on March 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the myoelectric orthotic device for the upper extremity (CPT L8702) and related services.
You asked the Plan to provide coverage for this device. You say that this device could be medically beneficial for the enrollee. The Plan denied your request. The Plan says this device is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a myoelectric orthotic device for the upper extremity (CPT L8702) and related services. The Maximus Physician Reviewer determined that the requested myoelectric orthotic device is considered medically reasonable and necessary in this case. The Plan requested a reopen noting that it is incorrectly stated that the enrollee has been using the myoelectric orthotic device for the past 12 months. This is not stated in the appeal letter. The medical records show the enrollee has a medical history that includes multiple strokes which have resulted in left arm weakness. However, the plan is correct in this case. The documentation does not support that the MyoPro Motion G Orthotic device is medically reasonable and necessary. The clinical documentation by the ordering physician does not support that the requested orthotic device is an accepted standard of medical practice that meets but does not exceed the enrollee's medical need and does not indicate that the device is at least as beneficial as existing and available medically appropriate alternatives.
There is insufficient medical literature with controlled studies demonstrating the efficacy of this device. Controlled trials do not support that daily function is improved with the use of the device. Studies to date are of small size and take place in controlled environments. Additional studies are necessary to establish efficacy. The evidence is insufficient to determine the effects of this technology on health outcomes. There are no long-term data for the use of these devices. Therefore, this device would not be covered by Medicare.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to provide coverage for the myoelectric orthotic device for the upper extremity (CPT L8702) and related services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is suitable for transfer to an 
LTAC. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and is currently unstable for transfer to an LTACH. 
 
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's status is unstable and critically ill, as there are several pending orders, 
worsening changes on the chest x-ray, and the etiology of the respiratory failure is still being investigated. 
There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is 
receiving appropriate care at the present setting. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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 was admitted with acute hypoxic respiratory failure in the setting of 
COVID-19 infection and pulmonary edema form congestive heart failure exacerbation. The record indicates 
that the enrollee remains critically ill and still requires acute care services. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that she is not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules are not satisfied. The requested service cannot be 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: Favorable

 
We decided that the Plan has to pay for SelectMDx, unlisted molecular pathology (81479) provided October 6, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are asking for this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says that that medical necessity has not been 
substantiated. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found NCCN Guideline Version 2022 Prostate Early Detection, includes the following statement 
regarding this test: Overall, the panel believes that SelectMDx score is potentially informative in patients who 
have never undergone biopsy, and it can therefore be considered in such individuals. SelectMDx (81479) 
provided October 6, 2021 is/was 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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for SelectMDx, unlisted molecular pathology (81479) provided October 6, 2021.  
 
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.