Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve three occupational therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that occupational therapy is needed to improve 
strength and increase function. The Plan denied your request. The Plan says that additional occupational 
therapy 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 therapy visits. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the clinical documentation shows that the 
enrollee is making functional improvements and improvements with strength but still requiring significant 
functional assistance with activities of daily living. The physician reviewer also found that the complexity of 
the clinical situation would require the professional guidance and treatment of an occupational 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 therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve three occupational therapy visits.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 you are currently undergoing treatment at an acute care hospital. You were 
transiently intubated/ventilated but are no longer intubated/ventilated. There is no evidence that you require 
services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same 
level of care, there is no advantage in transferring you to the LTACH. You can remain at the current acute care 
hospital until such time as no acute services are required. You can then be transferred/discharged to a lower 
level of care for any ongoing long term care needs. 
 
  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that the requested prostate artery 
embolization is medically necessary. The Plan denied your request. The Plan says the requested prostate artery 
embolization is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve prostate artery embolization. Our 
reviewer says that the requested prostate artery embolization is not medically necessary. Our physician 
reviewer found the records do not show that the enrollee has intractable prostatic bleeding.  
 
Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign 
prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy.  
The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside 
of a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding 
radiation exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with more traditional methods (eg, transurethral resection of the prostate [TURP], and adverse 
events. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for measurement of post-voiding residual urine and/or bladder capacity by 
ultrasound provided to the enrollee on November 26, 2021. 
 
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 that the place of service was inappropriate for this procedure. 
 
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 51798 is "Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-
imaging." 
 
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 supported by the medical records. Our reviewer found that per the coding guidelines and review 
of the procedure codes billed, there are no restrictions on CPT 51798 as far as place of service. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
measurement of post-voiding residual urine and/or bladder capacity by ultrasound provided to the enrollee on 
November 26, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services (CPT code(s): G0299 and 
G0151) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee is in need of home 
health services and has attached medical records to prove medical necessity. The Plan denied your request. The 
Plan says there are in-network provider(s) within a reasonable distance from the enrollee's location that can 
provide this service or item. 
 
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 
the home health services (CPT code(s): G0299 and G0151) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive the 20% coinsurance for a life vest.
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The
Plan denied your request. The Plan says this coinsurance was charged based on the equipment used and the
Plan contract agreement. Maximus overturned the Plans denial stating records to confirm use of the equipment
were not received. The Plan requested a reopen and provided documentation to show that you were fitted for
the vest on September 2, 2021, and the vest was returned on November 4, 2021.
The Plan is correct in this case. 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 20% coinsurance for durable medical equipment.
Based on the records provided, you used this equipment, and this equipment requires coinsurance. 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 20% coinsurance for a life vest provided from October 2, 2021, to November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the in-network benefit rate for palliative care to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve palliative care at the in-network rate. You say that the requested provider is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage at the in-
network rate have not been met. 
 
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 at the in-network rate 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 out-of-network items/services at the in-network rate. Therefore, we decided that 
the Plan does not have to pre-approve the in-network benefit rate for palliative care to be provided by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker (99998). 
 You asked the Plan to pre-approve a rollator walker. You say that with a rollator you will be able to move more 
normally. The Plan denied your request. The Plan says there is not enough information provided to support that 
the requested item is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a rollator walker. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates that the enrollee with unknown clinical history has a 
request for a rollator. However, despite multiple attempts including attempts by staff, and an Intent to Deny 
Fax the clinical information supporting the request and a signed physician order was not received. Section 
1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been 
furnished such information as may be necessary in order to determine the amounts due such provider". It is 
expected that the patient's medical records will reflect the need for the care provided. The review has 
determined that the records do not show that the enrollee meets the criteria for a walker. The medical records 
provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 rollator walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a rollator walker (99998).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you had painful plantar fasciitis five years ago with back and hip pain. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) admission. 
 
You asked the Plan to pre-approve the LTACH admission. You say that the admission is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the LTACH admission is 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 admission. Our reviewer 
says that the requested LTACH admission is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate there are services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Therefore, the 
reviewer found that transfer to LTACH 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 the LTACH admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octreotide. 
 
You asked the Plan to pre-approve Octreotide. You say that the requested Octreotide is medically necessary. 
The Plan denied your request. The Plan says the requested Octreotide is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Octreotide. Our reviewer says that the 
requested Octreotide is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of Angiodysplasia of colon and arteriovenous malformation of upper gastrointestinal 
tract. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. 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 Octreotide have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Octreotide.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac rehabilitation services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation submitted provides no additional information that justifies this 
request. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical necessity of cardiac rehabilitation in the absence of cardiac surgery or 
percutaneous coronary intervention, heart valve repair, or angina pectoris. An exhaustive review of the literature shows evidence of clinical benefit of cardiac rehabilitation in patients with certain events such as 
acute myocardial infarction or revascularization. Hence, practice guidelines have been formulated to define 
patient groups most likely to achieve meaningful benefit from a cardiac rehabilitation program. In summary, 
cardiac rehabilitation is not clinically warranted and not considered medically reasonable or necessary in your 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac rehabilitation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 osteomyelitis, surgical wound 
infection, and sepsis. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/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 inpatient rehabilitation facility (IRF) admission and services.