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

 
We decided that the Plan does not have to pay for urine PCR (polymerase chain reaction) testing (87798, 
87481) billed for date of service January 25, 2022. 
 
You asked the Plan to pay for urine PCR testing. You say that this test was reasonable and necessary and 
should be paid. The Plan denied your request. The Plan says this testing was not medically necessary or 
reasonable. 
 
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 pay for urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that review of the literature indicates that the standard of care for the evaluation of urinary 
incontinence is urinalysis with urine culture and sensitivity. Multiplex PCR is noninferior to urine culture for 
detection and identification of bacteria. Further investigation may show that the accuracy and speed of PCR to 
diagnose urinary tract infection (UTI) can significantly improve patient outcomes. However, at this time, PCR 
testing is considered unproven and not medically necessary. The review has determined that the items/services 
at issue in this case are 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 urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR (polymerase chain reaction) testing (87798, 87481) billed for date of service 
January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested services. You say that a BiPAP cannot provide the same 
support. The Plan denied your request. The Plan says settings that could be delivered by BiPAP is not covered. 
 
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 pre-approve the requested services. Our physician 
reviewer found that the enrollee has acute on chronic respiratory failure from chronic obstructive pulmonary 
disease. The record indicates that the enrollee was successfully treated with BiPAP in the hospital and that a 
sleep study did not demonstrate the need for noninvasive positive pressure ventilation. The documentation does 
not contain sufficient detailed information to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine. The plan has indicated coverage for such a device is available upon request. The elements of 
the coverage criteria are not satisfied.  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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a seat lift chair and mechanism.
You asked the Plan to provide coverage for a seat lift chair and mechanism. You say that this item is medically necessary. The Plan denied your request. The Plan says all of the required Medicare criteria for coverage are no met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all the conditions listed in the Medicare rules are met. Medicare does not cover the upholstered chair often sold with a seat lift mechanism. Based on the medical records provided, you do not meet all the required coverage criteria. The medical records also do not clearly state that you are ambulatory. Therefore, we decided that the Plan does not have to provide coverage for a seat lift chair and mechanism.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility 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 enrollee's nursing medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for a foot infection and had a partial amputation of the foot. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via disc NP allograft injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee failed conservative 
treatment. The Plan denied your request. The Plan says there is not enough evidence to prove this procedure is 
effective. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic back pain. He had a fusion at L4-L5. He has had radiofrequency 
ablation at L2-L3 and L5-S1 bilaterally without sustained benefit. He has had medication trials, physical 
therapy and a home exercise program. The requested service is an experimental/investigational procedure.  
Therefore, the request is deemed 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Via disc NP allograft injection.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37242. We decided that the Plan does not have to pay for 35371 and 
36246.  
 
You asked the Plan to pay for vascular surgical services provided to the enrollee on June 9, 2022.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 37242.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for CPT 37242. Our reviewer says that there is 
satisfactory documentation that four Interlink coils were placed in the left common iliac artery. This satisfies the documentation requirements of using 37242. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
37242.  
 
We also decided that the Plan does not have to pay for 35371 and 36246. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
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 for CPT 35371 and 36246. Our reviewer says that the 
procedure at the left groin constituted failure of percutaneous access requiring conversion to open with femoral 
cutdown and repair. This is represented by code 34812. Therefore, CPT 35371 is not supported. With respect to 
code 36246, this represents selective catheterization of a second order branch artery. The documentation does 
not satisfactorily describe requiring selective access of the second order vessel to place a catheter in the left 
common iliac artery.  If the catheter was unilateral this would be a nonselective catheterization, if the catheter 
was contralateral this would be a first order catheterization. CPT 36246 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 35371 and 36246 have not been met. Therefore, we decided that the Plan does 
not have to pay for 35371 and 36246. 
 
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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the Genesight psychotropic assay. We decided that the Plan does not 
have to pay for the MTHFR genetic testing.  
 
You asked the Plan to pay for the Genesight psychotropic assay provided on October 18, 2021. You say that 
these services should be covered. The Plan says that the services provided are not a covered benefit. 
 
 
We decided that the Plan has to pay for the Genesight psychotropic assay.  The Plan follows Medicare rules. The rules say that Medicare health plans must make reasonable and diligent 
efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The file does not support reasoning as to why this testing is not being covered by the Plan. This means that the 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not substantiate their denial for this service. Therefore, we decided 
that the Plan has to pay for the Genesight psychotropic assay.  
 
We also decided that the Plan does not have to pay for the MTHFR genetic testing. 
 
The Plan follows Medicare rules. Medicare rules say that testing for the MTHFR gene is only covered in 
enrollees who are pregnant. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was pregnant for 
the MTHFR testing to be covered. This means the file does not show that the enrollee had a medical indication 
for which Medicare will cover the MTHFR genetic testing. Therefore, we decided that the Plan does not have 
to pay for the MTHFR genetic 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has relapsing remitting 
multiple sclerosis. She has not tried and failed the Plan's required drug, Kesimpta. The records do not support 
that the required drug would be contraindicated or less effective; therefore, Ocrevus is 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 Ocrevus.
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 needs an intensive rehab program to 
regain his previous functional status. The Plan denied your request. The Plan says the enrollee cannot tolerate 3 
hours of intense therapy a day. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for myocardial infarction and congestive heart failure. 
His medical problems are stable.  There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. He does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy 
program. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the clinical information provided 
supports the need for a CardioMEMS device. The Plan denied your request. The Plan says the device is 
experimental and non-covered. 
 
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 a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a per-oral pyloromyotomy (POP) procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure will improve the 
enrollee's quality of life. The Plan denied your request. The Plan says the clinical effectiveness has not been 
demonstrated. 
 
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 requested services. Our physician 
reviewer found that per examination of available contemporary citations, the POP procedure is a novel 
technique that while promising is not standard-of-care. Further, available data suggests that the enrollees 
dysmotility may be global rather than confined to the upper gastrointestinal tract. That said, available 
documentation does not support that her symptoms are medically-refractory. She reported diarrhea with 
conventional anti-constipation therapy. Of further concern unique to the enrollees body habitus and co-
morbidities, she is high risk for endoscopic sedation. As such, the medical appropriateness and necessity of the 
POP procedure in her case is not demonstrated.  
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a per-oral pyloromyotomy (POP) procedure.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee's medical needs are being met in 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. 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. The health plan has approved ongoing care 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 long term acute care hospital (LTACH) services.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this time because 
his infection is getting worse, his heartbeat is irregular, and he needs imaging that cannot be performed at this 
time due to lack of venous access. The Plan says that the enrollee is receiving the cared needed in the hospital 
where he is now, and there is no need for transfer to the LTACH at this time. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. 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. The health plan has approved ongoing care 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 long term acute care hospital (LTACH) services.