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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee can only ambulate 7 feet. The Plan 
denied your request. The Plan says the denial of SNF care is correct. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Infed and Venofer. 
 
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 Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no indication 
that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Oncotype DX testing. 
 
You asked the Plan to pre-approve Oncotype DX testing. You say that the requested Oncotype DX testing is 
medically necessary. The Plan denied your request. The Plan says that the requested Oncotype DX testing is 
not medically necessary. 
 
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 pre-approve Oncotype DX testing. Our reviewer 
says that the requested Oncotype DX testing is medically necessary. Our physician reviewer found based on the 
documentation provided, the enrollee was clinically node negative and meets LCD criteria. The requested 
Oncotype DX testing is medically reasonable and necessary for the enrollee in this case, as this test follows 
National Comprehensive Cancer Network (NCCN) Guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Oncotype DX testing have been met. Therefore, we decided that the Plan has to 
pre-approve Oncotype DX testing.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 You asked the Plan to pre-approve continued services. You say that the enrollee is not well enough to go home. 
The Plan denied your request. The Plan says the enrollee no longer requires skilled services on a daily basis. 
 
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 continued services. Our physician 
reviewer found that the enrollee was admitted to a skilled nursing facility after an acute care hospitalization. 
The enrollee has remained medically stable and has been receiving skilled rehab services. The most recent 
therapy documentation indicates the enrollee is able to ambulate short distances using a walker and without 
hands on assistance. The enrollee does not have any complex daily wound care, parental medications or 
required care for a new or malfunctioning feeding tube. The enrollee does not require any skilled services on an 
inpatient basis, at a skilled level of care. Therefore, continued care 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myoelectric controlled upper-limb orthosis (L8702). 
 
You asked the Plan to pre-approve the upper-limb orthosis. You say that the requested orthosis is medically 
necessary. The Plan denied your request. The Plan says that the requested item 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 upper-limb orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for the enrollee's condition. There is insufficient evidence in the literature that the MyoPro orthosis will 
improve the long-term outcomes for the enrollee or will increase participation in bi manual activities. 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 upper-limb orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a myoelectric controlled upper-limb orthosis (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA scan. 
 
You asked the Plan to pre-approve CTA scan. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has peripheral vascular disease. They have a wound that 
isn't healing. The CTA is to look for progression in their vascular disease. There is no indication that the results 
of the CTA will change their treatment plan. 
 
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 CTA scan. Our reviewer says this is not medically necessary. Our physician reviewer found there is no indication in the medical record assessments that additional CT scanning is required or desired. There is no documentation that the planned angiogram can't be performed, or that additional information is needed.
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTA scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CTA scan.
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 you are unable to stay in the hospital and you require 
therapy to regain mobility. The Plan denied your request. The Plan says ongoing skilled care can be provided in 
an alternate setting. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
Your care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have documented skilled nursing needs. As such, the requested home health skilled nursing services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0669). 
 
You asked the Plan to pre-approve the device. You say that this si medically necessary. The Plan denied your 
request. The Plan says the clinical records do not support lymphedema extended to the chest, trunk, or 
abdomen. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has lower extremity lymphedema. Per the documentation, she has attempted exercise, 
elevation, and compression garments. She was also recently prescribed Lasix by her physician. However, there 
is insufficient documentation regarding the trial of a standard pneumatic compression pump with objective 
measurement and a failure to reduce the patients lymphedema. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0669).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a knee orthosis (L1833) provided on July 29, 2022.

You asked the Plan to waive the coinsurance for a knee orthosis. You say that payment of the cost-sharing would be a financial hardship for you. 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 20% coinsurance for durable medical equipment (DME) and related supplies.

You have been asked to pay 20% coinsurance for a knee orthosis. This item/service falls within the durable medical equipment (DME) and related supplies 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 coinsurance for a knee orthosis (L1833) provided on July 29, 2022.

Your complaint about receiving erroneous or incomplete information from representatives of the durable medical equipment supplier is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the anterior cervical discectomy and fusion (ACDF) 
coded as 22551, 22522, 22846 and 22853. 
 
You asked the Plan to pre-approve the spinal surgery. You say that you do not believe you should be denied 
due to you being a smoker. This should be covered as a no-fault claim because you are not a smoker. The Plan 
denied your request. The Plan says the requested service 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 spinal surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for cervical radiculopathy and presented with chronic 
neck pain that radiates down both arms. The exam reveals tenderness to palpation to the bilateral trapezius paracervical region, greater on the left than the right. Increased pain and restriction in range of motion. Strength 
and sensation are intact, with numbness noted in the left hand. However, detailed documentation is not evident 
regarding significant neurological deficits on the recent exams that corroborate with the requested surgical 
levels. Additionally, the provided diagnostic imaging studies did not corroborate significant disease at the 
requested surgery levels to reasonably support the requested procedure. Moreover, the enrollee is noted to have 
started the smoking cessation process; however, a follow-up was not provided to corroborate complete smoking 
cessation. 
 
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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the anterior cervical discectomy and fusion (ACDF) coded as 22551, 22522, 22846 
and 22853.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enrollment in the special supplemental benefits for 
chronically ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve SSBCI benefit. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI benefit have been met. Specifically, medical records were not provided for this case. The record shows that the Plan attempted to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve enrollment in 
the special supplemental benefits for chronically ill (SSBCI) benefit.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. 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 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 Darzalex Faspro. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the use is supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested 
drug is safe and effective and otherwise reasonable and necessary for 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 Darzalex Faspro have been met. Therefore, we decided that the Plan has to pre-
approve Darzalex Faspro.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
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 that you have had significant weight 
loss following bariatric surgery. The records do not document you have functional impairment or skin rashing 
that has not responded to conservative treatment. The records do not support that the panniculectomy is 
reasonable and medically necessary at this time. 
 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 a panniculectomy.  
 
Local Coverage Determination (LCD) L39051 referenced by the Plan is not binding for Part B Medicare for the 
state of Wisconsin and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve root block. 
 
You asked the Plan to pre-approve a nerve root block. You say that a nerve root block is medically necessary. 
The Plan denied your request. The Plan says the requested nerve root block does not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 nerve root block. Our reviewer says 
that the requested nerve root block is not medically necessary. Our physician reviewer found that the use of 
selective nerve root blocks to treat paraspinal pain is not indicated. 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 a nerve root block have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a nerve root block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service December 
12, 2022. 
 You asked the Plan to pay for procedure code 77002. You say that this service should be separately payable as 
it was medically necessary. The Plan denied your request. The Plan says payment for code 77002 is bundled 
into payment for code 64454. 
 
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 77002 
is a column II code to column I code 64454. 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 77002 billed for date of service December 12, 
2022.