Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve placement of the CardioMEMs device. 
 
You asked the Plan to pre-approve the CardioMEMs procedure. You say that it is felt that there is sufficient 
evidence to support the use of this device for the enrollee's condition. The Plan denied your request. The Plan 
says that the current literature is not sufficient to support the medical necessity of this treatment. 
 
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 the CardioMEMs procedure. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a medical history that includes coronary artery disease, coronary 
bypass surgery, ischemic cardiomyopathy, atrial fibrillation, diabetes, hypertension, and chronic obstructive 
pulmonary disease. The enrollee was hospitalized from 10/30/2022 to 11/1/2022 with acute on chronic 
congestive heart failure and acute hypoxemic respiratory failure.  
 
The CardioMEMS heart failure system was previously approved by the Food and Drug Administration (FDA) 
for use in patients with New York Heart Association class III heart failure who had been hospitalized for heart 
failure in the last year. A recent approval expands the indications for use in patients with New York Heart 
Association class II heart failure, and for those with increased natriuretic peptides. The documentation in the 
case file support that this standard was met, based on the medical records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMs procedure have been met. Therefore, we decided that the Plan 
has to pre-approve placement of the CardioMEMs device.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional speech therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the 21 visits of additional speech therapy cannot be considered 
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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional speech therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that your condition is worsening, and network 
providers are ineffective with treatment. The Plan denied your request. The Plan says network providers are 
available to render necessary care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the a computed tomography (CT) scan provided on August 
13, 2022. 
 
You asked the Plan to pay for the CT scan.. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment.   
  
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 August 4, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the a computed 
tomography (CT) scan provided on August 13, 2022.
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 meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says LTACH services are 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 all medically necessary care is being provided in the current acute care setting,  
and there are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on July 
6, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you would like the timely filing 
limit to be extended, as the transition in the authorization process delayed this claim. The Plan denied your 
request. The Plan says this claim was received on November 7, 2022, which is past the allowed 12-month 
timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the automatic external defibrillator was not filed until November 7, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator (K0606) 
provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra ACTPen medication. 
 
You asked the Plan to pre-approve Actemra ACTPen medication. You say that the enrollee cannot take TNFi's 
due to family history of demyelinating syndromes (multiple sclerosis). The enrollee needs an anti-IL-6 agent 
(Actemra) urgently. The Plan denied your request. The Plan says The requested medication for moderately to 
severely active rheumatoid arthritis falls under part D, and is not covered under part B. 
 
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 Actemra ACTPen 
medication.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for discharge to 
LTACH level of care and is the only safe option due to the need of hourly nursing care. The Plan denied your 
request. The Plan says criteria for LTACH admission has not been met, the enrollee's needs are being met at the 
current acute setting. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 10 additional physical therapy (PT) visits for
the enrollee.
You asked the Plan to provide coverage for 10 additional physical therapy (PT) visits. You say that at the time
of the appeal, additional therapy was 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 apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for 10 additional
physical therapy (PT) visits. The Maximus Physician Reviewer determined that the enrollee had not met all
reasonably appearing therapy goals and would require the assistance and treatment of a professional therapist to
meet. Therefore 10 additional outpatient physical therapy sessions were determined to be medically necessary.
The plan has stated that it disagrees with our consultant's determination. The Plan notes that the enrollee had
already received 20 PT visits. The Plan noted the guidelines state if at any point in the treatment it is
determined that the treatment becomes repetitive and does not require the unique skills of a therapist, the
services are non-covered. The medical records show the enrollee was a then 66-year-old woman who
underwent a cervical discectomy and spinal fusion. Physical therapy (PT) began on May 24, 2022. On July 21,
2022, the enrollee had exceeded many of the goals set for cervical range of motion. The physical therapist
writes that the enrollee would benefit from skilled PT of manual treatments to improve thoracic mobility to
compensate for the limited range of motion (ROM) in her cervical spine, and progression of exercises to
continue to improve right upper extremity strength. The Plan is correct in this case. The documentation does
not support that the continued skills of a professional therapist were required to safely and effectively provide
treatment, that the services could be safely and effectively performed only by a therapist, or for physical
therapy and occupational therapy, by or under the supervision of a therapist. Medicare coverage criteria were
not met at the time of the appeal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional physical therapy (PT) visits have not been met. Therefore, we
decided that the Plan does not have to provide coverage for 10 additional physical therapy (PT) visits for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final
restoration) (D3320) provided June 20, 2022.
You asked the Plan to pay for these services. You say that this procedure was not planned. The Plan denied
your request. The Plan says that this service is not covered under your benefits. Maximus overturned the Plan's
denial because there was no Evidence of Coverage submitted. The Plan requested a reopening and provided the
required Evidence of Coverage.
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 pay for the
endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided to the
enrollee from December 23, 2021, to January 18, 2022.
You asked the Plan to pay for the pneumatic compression device. You say that the enrollee was treated for
post-surgical lymphedema. The Plan denied your request. The Plan says the pneumatic compression device is
not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
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 the pneumatic compression device (E0675) provided to the enrollee from December 23, 2021, to
January 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 10 additional physical therapy visits.
You asked the Plan to provide coverage for 10 additional visits. You say that at the time of the appeal,
additional physical therapy was medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria for additional visits 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 10 additional
physical therapy (PT) visits.
The Maximus Physician Reviewer additional physical therapy sessions to be medically necessary. The Plan
requested a reopen and stated Maximus did not apply the correct criteria under LCD 33631. The medical
records show you have unilateral primary osteoarthritis of the left knee. You had total left knee replacement
surgery on August 16, 2021. On September 23, 2021, all studies were normal showing left tibial and left
common peroneal neuropathy. On May 10, 2022, at an Orthopedic Surgery follow-up, you stated your quality
of life was extremely poor. The orthopedist noted you should continue to take Gabapentin and reiterated he did
not feel that there are good active forms of treatment for tibial and peroneal neuropathy, which was present
since the time of surgery. On June 3, 2022, an orthopedic and rehabilitation physician document that he
suspects that soft tissue trauma of the lateral release with associated scarring is the most likely cause of pain.
An Ortho Sports and Spine Rehabilitation physical therapy (PT) re-evaluation on May 19, 2022, determined
that you would continue to benefit from skilled PT to address his restricted range of motion, decreased strength,
and significant functional limitations. However, the available documentation is insufficient to support that the
unique skills of a professional therapist for 10 additional PT visits are required at this point. Medicare coverage
criteria were 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 ten additional visits have not been met. Therefore,
we decided that the Plan does not have to provide coverage for 10 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve additional physical therapy services. You say that at the time of the appeal,
additional services were medically necessary. The Plan denied your request. The Plan says the 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 10 additional
physical therapy (PT) visits. The Maximus Physician Reviewer determined that the clinical documentation
showed that not all the physical therapy goals which appeared to be reasonable had been met, and it was
documented that the enrollee was meeting some short-term goals and making progress. The Plan requested a
reopen and notes that visits were repetitive for a neurologic condition, and that goals and progress were not
clear. The medical records show the enrollee was a then 64-year-old woman with pain in the left shoulder.
Diagnoses include multiple sclerosis and unsteadiness on feet. The enrollee was being seen twice weekly in PT.
Electrical stimulation and ultrasound were being used.
On May 10, 2022, the enrollee reported improvement in balance and arm function, however, she had fallen 2
times. Electrical stimulation, ultrasound, and manual therapy/mobilization were used. From June 2, 2022,
through June 21, 2022, therapies included electrical muscle stimulation, myofascial release and cupping, and
therapeutic exercise. The enrollee reported improvement with PT exercise and treatment. The enrollee had
received multiple physical therapy sessions for her condition, which includes multiple sclerosis. There is
limited documentation of significant improvement in the enrollee's pain, range of motion, strength, and
function with physical therapy over several weeks. Therefore, the Plan is correct in this case, documentation
does not support that the continued skills of a therapist were required for the enrollee at the time of the appeal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy services have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve additional therapy services. You say that at the time of the appeal additional
therapy 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 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 additional PT
visits.
The medical records show the enrollee the enrollee is a 72-year-old woman with bilateral primary osteoarthritis
of the hips. The medical history is notable for Parkinson disease. It is documented that the enrollee requires a
walker and PT to manage imbalance and limit falls. The initial PT evaluation occurred on April 12, 2022.
Short-term goals (4 weeks) and long-term goals (8 weeks) were established. The only available PT Progress
Note available in the case file is dated May 5, 2022. It is noted that the enrollee had 3 falls in the previous
week. The plan was for a PT frequency of 2 times per week for 8 weeks. The Plan is correct in this case, the
available documentation is insufficient to support that the unique skills of a professional therapist are required
for this enrollee to safely and effectively provide treatment, and that the services can be safely and effectively
performed only by a therapist, or by or under the supervision of a therapist.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional therapy services have not been met. Therefore, we decided that the
Plan does not have to pre-approve five additional physical therapy visits for the enrollee.