Persius/hicric huggingface dataset:
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 enrollee's chance to return home and maintain 
living at home will be significantly reduced if the opportunity to participate in an IRF program is denied. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a prefabricated knee orthosis. 
 
You asked the Plan to pre-approve prefabricated knee orthosis. You say that your doctor wants to try this 
because you are immobile without it. The Plan denied your request. The Plan says that the records do not show 
that you have knee instability present on examination. 
 
The Plan follows Medicare rules. Medicare rules state that prefabricated knee orthoses such as code L1852 are 
only covered for certain conditions. 
 
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 prefabricated knee orthosis. Our 
reviewer says that you meet criteria for the requested knee orthosis. Our physician reviewer found you have 
severe bilateral knee osteoarthritis. You have impaired mobility as well as pain that has not responded to 
medications or injections. There is documentation of deformity noted as well as a history of prior left side 
patellar fracture with a failure of surgical hardware. Therefore, this orthosis is 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 prefabricated knee orthosis have been met. Therefore, we decided that the Plan 
has to pre-approve a prefabricated knee orthosis.  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets acute IRF admission criteria and 
will require an intensive team for their care. You say that you expect the enrollee to improve in a reasonable 
amount of time and discharge home. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on April 10, 2021. 
 
You asked the Plan to pay for physicians services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 9, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for physicians services 
provided on April 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 15, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on March 10, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the file shows that the 
enrollee was admitted as an outpatient on the date of service at issue in this appeal. Code 99223 is an inpatient code. Based on this information, we decided that Medicare rules for coverage of procedure code 99223 have 
not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) 
provided on March 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service  
April 1, 2022, to April 30, 2022. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 1, 2022, to April 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
  You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the enrollee's ulcer 
is very big, and the nurse recommends the air mattress so the enrollee can heal and not get more ulcers. The 
Plan denied your request. The Plan says there is no documented medical necessity that states that the enrollee 
needs the requested item. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets at least one of the three criteria listed in the Medicare rules section of this letter. 
 
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 powered pressure-reducing air 
mattress. Our reviewer says that the enrollee does not meet the coverage criteria for a powered pressure-
reducing air mattress. Our physician reviewer found the documentation indicates that the enrollee has a Stage 
III pressure ulcer. There is no documentation of previous treatments or ongoing therapies. Our reviewer found 
there is no specific clinical rationale for the powered pressure-reducing air mattress (E0277). Our physician 
reviewer also found that the enrollee does not meet at least one of the criteria for coverage for a powered 
pressure-reducing air mattress. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for CT scans of the lumbar spine, the cervical spine, and a cardiac calcium scoring study.
You asked the Plan to provide coverage for several imaging studies. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus partially overturned the Plans denial. The Plan requested a reopen regarding the study for the calcium scoring as it was not included in the original Maximus decision.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a CT Cardiac Calcium Scoring study. The medical records show the enrollee is a 64-year-old man who was evaluated on 2/26/22 for primary prevention in a patient with DISH with vascular calcification noted on CT scan and concern for chest wall involvement and impact on pulmonary function. The enrollee's Active Problem List included Hypertension and Other hyperlipidemia. Medications included Losartan and Rosuvastatin.
The Plan is correct in this case. The 2018 ACC/AHA Cholesterol Guideline suggests that coronary artery calcium testing may be considered in adults 40-75 years of age without diabetes mellitus and with LDL-C levels =70 mg/dl-189 mg/dl at a 10-year atherosclerotic cardiovascular disease risk of =7.5% to less than 20% (i.e., intermediate risk group) if a decision about statin therapy is uncertain. The documentation does not support that a CT cardiac calcium scoring study was medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage for a CT cardiac calcium scoring study were not met. Therefore, we decided that the Plan does not have to provide coverage for the CT cardiac calcium scoring study.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from May 9, 2022, to 
May 31, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you believe this was a hospital visit and 
you should only pay a copayment of $90. 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 s $0 
copayment per day for days 1-20 and $178 copayment per day for days 21-100 for in-network SNF care.  
 
You have been asked to pay a $0 copayment per day for days 1-20 and $178 copayment per day for days 21-
100 for SNF care. For the days 1 to 20 you are being asked to pay a $0 copayment. The total amount you are 
being asked to pay is $534 ($178 x 3 days = $534) This item/service falls within the in-network SNF care 
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 SNF care provided from May 9, 
2022, to May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 25, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting.  Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on May 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (J0897). 
 
You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Xgeva. 
 
 
 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 Xgeva. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Xgeva. Our physician reviewer found the requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step one alternative. Our reviewer found that the record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. The 
elements of the coverage criteria are not satisfied. Our physician reviewer also found that 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for these accessories.
You asked the Plan to provide coverage for these power wheelchair accessories. You say that these accessories are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not perform a complete review of the records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for power wheelchair accessories E2377, E2311 and E2313. The Maximus Physician Reviewer determined that these accessories are medically necessary. The Plan requested a reopen and argues that the enrollee's documented functional bilateral upper limb abilities are adequate for the member to be able to control the power options/features using their own switches which are included in the allowance of these power options/features. The Plan notes that the enrollee was determined to be independent with feeding, grooming, dressing, and bathing. The medical records show the enrollee is a 48-year-old woman with a diagnosis of multiple sclerosis. The Progress Notes document right and left upper extremity and lower extremity strength of 3 out of 5. At that time, the enrollee was using a standard manual wheelchair that was not meeting her needs. It is documented that the enrollee was 1-2 person assist for toileting, dressing, grooming, and bathing.
The Multidisciplinary Evaluation Report documents that the enrollee was independent with feeding and grooming. Therefore, the Plan is correct in this case. The clinical documentation does not support that E2377, E2311, and E2313 were medically reasonable and necessary for the enrollee in this case. The documentation supports that the enrollee would reasonably be expected to utilize the switches for the accessories at issue. 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 power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to provide coverage for the requested power wheelchair accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the SPRINT percutaneous nerve 
stimulator (PNS). 
 
You asked the Plan to pre-approve the SPRINT PNS placement. You say that it is felt that this device will be 
beneficial for the enrollee's condition. The Plan denied your request. The Plan says this is not a medically 
necessary treatment. 
 
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 SPRINT PNS placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has right knee pain following patellectomy 5 year ago. The 
knee pain compounds her back pain. The SPRINT was prescribed to assist with this pain; however, there is 
insufficient evidence in the medical literature to support that the SPRINT percutaneous nerve stimulator is 
reasonably expected to be safe and effective in this 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 SPRINT PNS placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the SPRINT percutaneous nerve stimulator (PNS).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance tablets. 
 
You asked the Plan to pre-approve Trulance tablets. The Plan denied your request. The Plan says self-
administered drugs like Trulance are covered by the pharmacy (drug) benefit. 
 
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 Trulance tablets.  
 
Benefits for Trulance tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.