Persius/hicric huggingface dataset:
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 are requesting reconsideration for the denial of 
an IRF admission. You say you feel you would do better in the hospital setting for rehabilitation instead of a 
nursing home. The Plan denied your request. The Plan says you do not meet the medical necessity guidelines 
for admission to an IRF. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement (D6057) and abutment supported porcelain/ceramic crowns (D6058).
You asked the Plan to pre-approve custom fabricated abutments-includes placement and abutment supported porcelain/ceramic crowns. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that these services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement (D6057) and abutment supported porcelain/ceramic crowns (D6058).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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 an ILR 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 that the enrollee has a history of 
palpitations. There is no documentation to suggest a history of unexplained syncope, cryptogenic stroke, or any 
other apparent indication for an ILR. The services are not reasonable or medically necessary based on the 
submitted records. 
 
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 implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like the Plan's denial to be reconsidered given the additional information, and a Group 3 power 
wheelchair with all medically necessary accessories be approved so the enrollee can be provided with the 
medical equipment that they desperately need. The Plan denied your request. The Plan says there is not a 
medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has adequate strength in upper extremities to 
manage standard switches on a power wheelchair. Our reviewer also found that this request exceeds what is 
necessary to meet the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires antibiotics and 
wound care. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage bioimpedance spectroscopy (BIS) for the enrollee.
You asked the Plan to provide coverage bioimpedance spectroscopy (BIS). You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bioimpedance spectroscopy (BIS). The Maximus Physician Reviewer determined that bioimpedance spectroscopy for breast cancer related lymphedema assessment has become a standard of care for prevention and treatment. Clinical measurements are obtained initially to establish a baseline before breast cancer treatments and afterward at intervals to track changes during treatment. Alternatively, changes in arm circumference or volume relative to the contralateral normal limb can be performed. Given that the highest risk of developing lymphedema is within the first three years of treatment and that early intervention can limit progression of disease, high-risk patients should be followed closely in this period.
Given the treatment his patient has received for her breast cancer she is at increased risk of lymphedema. The service was determined to be reasonable and medically necessary.
The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria. The medical records show the enrollee was a then 71-year-old woman with a history of extensive high grade ductal carcinoma in situ. The enrollee underwent a left mastectomy on April 28, 2022. The enrollee was treated with Taxol and trasuzumab. On October 18, 2022, follow-up visit, the oncologist documents no edema in the extremities. On October 11, 2022, physical therapy progress notes documents soft edema in the left wrist and forearm, as well as an increase in left arm girth measurements of up to 1.6 cm. On November 19, 2022, a letter from the oncologist states that the enrollee is at high risk of developing lymphedema as a result of treatment, and that the use of ImpediMed's L-Dex device is medically necessary.
Our Medical Director states the Plan is correct in this case. At the time of the plan's denial, the NCCN Guidelines Version 1.2022 Survivorship: Lymphedema did not recommend BIS in the management of lymphedema. The available evidence in the medical literature was insufficient to support that bioimpedance spectroscopy is 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 bioimpedance spectroscopy (BIS) have not been met. Therefore, we decided that the Plan does not have to provide coverage bioimpedance spectroscopy (BIS) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued use of an in-home ventilator (E0466) provided 
on December 17, 2022. 
 
You asked the Plan to pay for the continued use of of a ventilator. You say that the records support the 
enrollee's need for continued use of the home ventilator. The Plan denied your request. The Plan says continued 
use is not medically necessary. 
 
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 pay for the continued use of a ventilator. Our 
reviewer says that continued use of the home ventilator is not medically necessary. Our physician reviewer 
found the provided records indicate a diagnosis of severe chronic obstructive pulmonary disease, but no further 
detail is provided such as arterial blood gas results to confirm chronic respiratory failure. The reviewer found 
that the provided records do not show timely documentation in the enrollee's medical record showing usage of 
the item. Therefore, the reviewer found that continued use of the home ventilator 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 continued use of a ventilator have not been met. Therefore, we decided that 
the Plan does not have to pay for the continued use of an in-home ventilator (E0466) provided on December 
17, 2022.
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 need a doctor to help get your pain under control because the pain makes it difficult for you to get out of bed, walk, and do everyday tasks. The Plan denied your request. The Plan says that you do not require an intensive level of therapy requiring physician oversight.
Our Medical director looked at the case file and the reopen request. At issue is coverage for IRF care.
Our Medical Director states that the documentation does not support that the complexity of your nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment (A4595) provided on October 9, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid proof of delivery for the supplies provided in this case. Therefore, we decided that 
the Plan has to pay for the durable medical equipment (A4595) provided on October 9, 2022.  
 
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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs cannot be adequately 
cared for in their current condition at a skilled nursing facility or any other lower level of care. The Plan denied 
your request. The Plan says the requested LTACH admission is not medically necessary. 
 
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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement for 
teeth number 19, 30 (D6057 x 2), implant supported porcelain/ceramic crowns for teeth number 19, 30  
(D6065 x 2), and interim implanted crowns for teeth number 19, 30 (D6085 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items has been exhausted. Specifically, the Plan's contract states that  
2 dental implants are covered per year. The Plan has approved dental implants for teeth number 12 and 13. 
Therefore, you have exhausted the allowable benefit for the items requested in this case at this time. Therefore, 
we decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement for 
teeth number 19, 30 (D6057 x 2), implant supported porcelain/ceramic crowns for teeth number 19, 30  
(D6065 x 2), and interim implanted crowns for teeth number 19, 30 (D6085 x 2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a lipid panel provided on August 16, 2022.
You asked the Plan to waive the copayment for a lipid panel. You say that you only had one test done and you do not have control over where the test gets sent to be read. The Plan denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for other Medicare-covered laboratory tests that are not FIT tests.
You have been asked to pay a $10 copayment for a lipid panel. This item/service falls within the other Medicare-covered laboratory tests that are not FIT tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a lipid panel provided on August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction therapy provided from August 11, 2022, through September 6, 2022.
You asked the Plan to pay for mechanical traction therapy. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says mechanical traction therapy is not covered by Medicare or the Plan. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional documentation.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. Mechanical traction therapy is not a covered treatment. Therefore, we decided that the Plan does not have to pay for chiropractic services (mechanical traction therapy) provided from August 11, 2022, through September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection services (procedure code 20610, J7321, 
77002) rendered on November 9, 2022. 
 
You asked the Plan to pre-approve the services. You say that you have submitted medical records for medical 
necessity. The Plan denied your request. The Plan says the plan excludes coverage for services determined to 
be experimental and investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that viscosupplementation of joints other than the knee(s) are considered not reasonable and necessary, 
because it is an off-label use of the medication and it's use here is experimental/ investigational.  Therefore, the procedure was not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection services (procedure code 20610, J7321, 77002) rendered on November 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the guidelines do not support the use of Keytruda in this enrollee. who has HER2 
negative, PD-L1 negative, stable MSI, low TMB stomach cancer. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the requested use of 
Keytruda is not approved for the FDA's diagnosis. Per the National Comprehensive Cancer Network (NCCN), Pembrolizumab is based on testing for Microsatellite Instability (MSI) by polymerase chain reaction/next 
generation sequencing (PCR/NGS) or mismatch (MMR) by immunohistochemistry (IHC), PD-L1 expression 
by IHC, or high tumor mutational burden (TMB) by NGS. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.