Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. This enrollee was recently hospitalized with an 
acute exacerbation of COPD. Arterial blood gas was consistent with acute on chronic hypercarbic respiratory 
failure. Intubation was required. There is no arterial blood gas (ABG) done while stable to confirm chronic 
carbon dioxide (CO2) retention. If this enrollee does have chronic CO2 retention, may benefit from bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
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.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal IRF care was medically necessary. The Plan denied your request. The Plan says at the time of the appeal 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 coverage criteria.
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, you did not require IRF admission after your inpatient admission. Your needs could have been met at a lower level of care such as a skilled nursing facility or home health aide. Whether or not IRF care would benefit you at the time of the request is not of issue, you must actually meet the criteria for care at the time of the request.
Medicare rules for coverage of IRF care were not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair blood vessel, direct; intra-abdominal provided to the 
enrollee on February 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 35221 is considered inclusive to CPT 48150. 
 
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 35221 is "Repair blood vessel, direct; intra-abdominal." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does 
not support the use of procedure code 35221. It is included within the surgical package of CPT 48150. 
 
We looked at this coder'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 pay for repair blood vessel, direct; intra-abdominal provided to the enrollee on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing of 22 or more drug classes (G0483) 
provided on May 16, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the services at issue were 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 pay for definitive drug testing. Our reviewer says 
that the services at issue are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the condition of the enrollee did not meet the criteria for payment for definitive urine drug testing (UDT) for 22 or more drug classes. The diagnosis is medication management of long- term (current) 
drug therapy. The available medical record shows a definitive UDT panel for multiple drug classes was 
performed but does not show screening test results which are positive or inconsistent with prescription 
medications, dosing schedules, or history and expected results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing of 22 or more drug classes (G0483) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bath/shower chair, with or without wheels (E0240). 
 
You asked the Plan to pre-approve the bath/shower chair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve the bath/shower chair, with or without 
wheels (E0240).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (PSG) (95810). 
 
You asked the Plan to pre-approve a PSG. You say that the clinical documentation is clear and demonstrates 
the medical necessity for a sleep test. The Plan denied your request. The Plan says this request is not medically 
necessary because the enrollee has a valid sleep study for which they can obtain a new continuous positive 
airway pressure (CPAP) machine. 
 
The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography studies may be indicated 
for the conditions 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 PSG. Our reviewer says that a 
diagnostic polysomnogram is not medically necessary. Our physician reviewer found this enrollee has a 
diagnosis of obstructive sleep apnea, and has had several sleep studies and positive airway pressure (PAP) 
titrations over the years, since 2012. The most recent polysomnogram was March 8, 2022, confirming 
obstructive sleep apnea. Our reviewer found that the enrollee has never been able to tolerate a PAP device 
sufficiently to meet Medicare minimum criteria of at least 4 hours per day for at least 70% of days. The 
enrollee does not currently have a PAP device and is unable to get one because there is a balance owed to the 
vendor. Our reviewer also found that there does not appear to be a question about the diagnosis of obstructive 
sleep apnea, so a repeat diagnostic sleep study 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 a PSG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a polysomnography (PSG) (95810).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy assessment using the ImpediMed L-Dex testing device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for bioimpedance spectroscopy assessment using the ImpediMed L-Dex testing device. Our Medical Director states that the available evidence in the medical literature and the clinical documentation in this case are insufficient to support that bioimpedance spectroscopy is medically reasonable and necessary. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
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 bioimpedance spectroscopy assessment using the ImpediMed L-Dex testing device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 48-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
doctors appointments. The Plan denied your request. The Plan says the requested trips exceed your trip limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
48-trip limit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy, Carboplatin, Paclitaxel, Nivolumab, 
Palonosetron, Dexamethasone, Diphenhydramine, and Famotidine. 
 
You asked the Plan to pre-approve Yervoy, Carboplatin, Paclitaxel, Nivolumab, Palonosetron, Dexamethasone, 
Diphenhydramine, and Famotidine. 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 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 Yervoy, Carboplatin, Paclitaxel, 
Nivolumab, Palonosetron, Dexamethasone, Diphenhydramine, and Famotidine. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of drugs are not FDA-
approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy, Carboplatin, Paclitaxel, Nivolumab, Palonosetron, Dexamethasone, 
Diphenhydramine, and Famotidine have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy, Carboplatin, Paclitaxel, Nivolumab, Palonosetron, Dexamethasone, Diphenhydramine, 
and Famotidine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 3, 2022, to 
March 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of secondary diagnosis code J18.9 (pneumonia unspecified organism). The 
Plan denied your request. The Plan says the medical records do not support the billing of secondary diagnosis 
code J18.9 (pneumonia unspecified organism). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J18.9. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the 
medical records do not support the billing of secondary diagnosis code J18.9 (pneumonia unspecified 
organism). Our physician reviewer found the documentation indicated that the enrollee was treated for hospital-
acquired pneumonia, the clinical evidence in the medical record did not support the condition. The initial chest 
x-ray on March 8, 2022, only noted mild linear atelectasis in the right lung and stated that otherwise there was 
no definitive acute cardiopulmonary disease radiographically evident. A follow-up chest x-ray on March 16, 
2022, was obtained which noted moderate sized right pleural effusion with no focal opacity/consolidation and 
no acute findings. The final chest x-ray on March 19, 2022, indicated that there was no significant interval 
change in cardiopulmonary status. Review of the medical record found no confirmation of pneumonia by 
imaging studies. The review has determined that the documentation did not support J18.9 (pneumonia 
unspecified organism).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 3, 2022, to March 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
titration (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with average 
volume assured pressure support (AVAPS) and a back-up rate. As stated in the Local Coverage Determination 
(L33800): Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for acute inpatient hospital care is met in 
this case. Our physician reviewer found the enrollee is experiencing pain in her Left shoulder, affecting ADL's. 
Imaging and clinical exam support glenohumeral osteoarthritis. She has tried and failed conservative measures. 
She is undergoing a planned elective left shoulder surgery. The enrollee is medically stable with a past medical 
history of arthritis, asthma, hypertension, and hypothyroidism. The planned procedure listed under CPT codes 
23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory 
procedure. There is no documentation provided to support the expectation the enrollee will require a greater 
than 2 midnight stay. The review indicates that the record did not show that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on June 27, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that this care was necessary and was reported 
correctly. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 asked our coder 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 initial hospital care. Our reviewer says that the code used to 
report these services is not supported in the medical record. Our reviewer found the documentation includes an 
expanded problem focused history rather than a comprehensive history, a comprehensive exam, and medical 
decision making of moderate complexity rather than high complexity. Only one of the three key components of 
code 99223 have been met in this case. There is a more appropriate code to report the services provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for initial hospital care (99223) provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120) with an out-of-network provider. 
 
You asked the Plan to pre-approve the dentures. You say that you are requesting reconsideration for the denial 
of coverage for a complete set of dentures provided by an out-of-network dentist. The Plan denied your request. 
The Plan says only dental services provided by a participating general dentist are covered. The Plan also says 
only dental codes listed will be covered. 
 
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. 
 
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 a 
complete upper denture (D5110) and a complete lower denture (D5120) with an out-of-network provider.