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

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary for the enrollee. 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 noted that the Maximus reviewer did not consider that this member's ability to participate in intensive therapy was described as limited by the evaluating therapists, due to weakness, balance, and memory problems, that the enrollee used a walker or wheelchair at baseline, and that the physicians described resolution of the transient right sided weakness.
Medicare coverage criteria were not met.
The Plan is correct in this case. 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. Based on this the medical records provided, at the time of the appeal, the enrollees physical condition was not such that participation in an intensive therapy program would be possible. Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 the 
clinical documentation shows that you have had functional/clinical status change. You have had assessment by 
skilled nursing related to requested service - instructed on catheter care. The concern documented is primarily 
related to functional status change with multiple falls. The clinical documentation does not show that you 
would require continued home health skilled nursing. Thus, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CellSearch genetic panel rendered on November 29, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a history of malignant 
neoplasm of the prostate diagnosed in 2010 that was treated with radiation and hormonal therapy. The records 
do not support that the enrollee decided to seek further cancer treatment. The criteria for coverage are not met 
and the CellSearch testing was 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 pay for the CellSearch genetic panel rendered on November 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from August 29, 2022, to September 26, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs 
 
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 pay for 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 did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 pay for SNF care provided from August 29, 2022, to September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital visit (G0463) and prothrombin time (85610) 
provided on September 29, 2022, to October 27, 2022. 
 
You asked the Plan to pay for hospital visit (G0463) and prothrombin time (85610). You say that the service 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital visit (G0463) 
and prothrombin time (85610) provided on September 29, 2022, to October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items should be covered. The 
Plan denied your request. The Plan says these are not covered items. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675 and E0673).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says imaging to measure the amount of calcium deposits in the blood vessels that supply 
blood to your heart muscle (quantitative calcium scoring) is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that quantitative calcium scoring is not a covered service 
and will be denied as not medically necessary. 
 
The requested service is not considered reasonable or necessary by Medicare at this time. 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 quantitative calcium scoring.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF care 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 the Maximus reviewer did not consider that this enrollee's ability to participate in intensive therapy was described as limited by the hospital physical therapist, given their confusion, fatigue, shortness of breath, dizziness and overall decreased activity tolerance/endurance requiring rest breaks during a 17-minute exercise session.
The Plan is correct in this case. 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. Based on the medical records provided, at the time of the appeal, the records do not show the enrollee was expected to benefit from or participate in the type of intensive therapy provided in an IRF level of care. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
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 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 your condition or in widespread use for your condition 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term. There is insufficient evidence in the literature that this device will increase participation in both-handed activities. The MyoPro is 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 a MyoPro Motion G orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch brand diabetic testing supplies. 
 
You asked the Plan to pre-approve OneTouch supplies. You say that the enrollee has been using OneTouch 
strips. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for OneTouch supplies. Therefore, we decided that the Plan does not have to pre-approve OneTouch brand 
diabetic testing supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor and a full leg segmental pneumatic appliance. 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 follows Medicare rules. Medicare rules say that a PCD coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when certain 
requirements 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 a pneumatic compressor and a full leg 
segmental pneumatic appliance. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found as medical records do not document lymphedema of the chest, trunk or abdomen on physical 
examination of the enrollee or a four-week trial and failure of regular, daily, multiple-hour home usage of the 
standard pneumatic compression pump (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, 
then it cannot be said that the enrollee has unique characteristics that would indicate a segmented pump over a 
standard pump. Records indicate the duration of the standard pump trial was "30-60 minutes or as tolerated." 
 
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 pneumatic compressor and a full leg segmental pneumatic appliance have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) 
and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replace missing or broken teeth - complete denture (each 
tooth) (D5520) provided on December 12, 2022. 
 
You asked the Plan to pay for dental services. You say that the service you received should be covered under 
your insurance. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Replace missing or broken 
teeth - complete denture (each tooth) (D5520) is not covered under the Plans dental benefits. 
 
  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 pay for replace 
missing or broken teeth - complete denture (each tooth) (D5520) provided on December 12, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 clinical documentation shows that the enrollee has active medical comorbidities 
(HTN-hypotension), however, complex functional impairments have mostly resolved (supervision for 
ambulation/transfers) thus the complexity of the enrollee's nursing, medical and rehabilitation documented 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. IRF criteria is not 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for treatment of the health 
problem. 
 
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 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 this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this 
patient. There is insufficient evidence in the literature that this device will increase  participation in bimanual 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve the device. You say that the enrollee's symptoms are significant and 
conservative measures have not provided lasting relief. The Plan denied your request. The Plan says the records 
do not show a four week trial of an E0650 or E0651. 
 
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 documentation does not reveal objective evidence of  lymphedema of the chest, trunk, or 
abdomen. The documentation does not reveal unique characteristics that would indicate the segmented pump 
over a standard pump. The documentation does not reveal a four week trial and failure of the standard pump 
(E0651). The 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair. 
 
You asked the Plan to pre-approve a wheelchair. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested equipment will be used in a long-term care facility. Therefore, coverage 
criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a wheelchair.