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

 
We decided that the Plan does not have to pre-approve the Optimizer Smart system for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necesary. The Plan denied your 
request. The Plan says the requested testing is experimental and investigational. 
 
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 system. 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 whether implantation of the cardiac contractility modulation (CCM) system in this patient 
is medically necessary for the treatment of congestive heart failure (CHF) which has been deemed refractory to 
optimal medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical 
trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional 
capacity.  
 While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart system for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the notes do not show that the member's care specifically requires the 
involvement of a doctor in the field of rehabilitation medicine. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient is living at home with chronic 
respiratory failure and oxygen dependent chronic obstructive pulmonary disease and is having progressive 
weakness. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and 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. There is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis 51 or greater genes 
(81455) provided October 13, 2021 
 
You asked the Plan to pay for the genetic testing. You say that you believe these services were appropriate 
based on past medical history. The Plan denied your request. The Plan says the request for a panel of 51 or 
greater genes is not reasonable or 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 the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the targeted genomic sequence analysis 51 or greater genes (81455) is not included as a covered 
indication for prostate cancer in LCD L35396. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for targeted genomic sequence analysis 51 or greater genes (81455) provided October 13, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that you would like this service to be approved so you 
can manage your health. The Plan denied your request. The Plan says the PET scan you requested does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET scan. Our reviewer says that a 
PET scan is not reasonable and necessary. Our physician reviewer found the lung mass you have is chronic and 
stable, and not suspicious for malignancy. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 14, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you received a bill for an emergency 
medicine technician (EMT) that was dispatched. You say that you did not know of an EMT that was 
dispatched. You also say that you should not be responsible for this bill. The Plan denied your request. The 
Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 14, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on November 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission to be associated with an elective 
left total knee arthroplasty. 
 
You asked the Plan to pre-approve an inpatient admission. You say that your doctor strongly suggests you stay 
overnight after your knee surgery. The Plan denied your request. The Plan says there is no documentation 
provided to support the expectation that you will require a greater than two 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 an inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found an elective total left knee arthroplasty procedure was approved. This is a request for 
inpatient services following this non-emergent low risk procedure. Our reviewer found that recent notes did not 
show instability or high-risk clinical status that might suggest you would require hospital services that would 
likely cross 2 midnights following the proposed surgery. Our physician reviewer also found that following 
surgery, a reassessment of hospital care needs can be made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission to be associated with an elective left total knee 
arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 9, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on February 9, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Caris Molecular Intelligence(r) testing rendered on January 14, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met.  
 
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 these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee with advanced ductal carcinoma 
and positron emission tomography (PET) scan showing lesions in the skeletal and liver areas, suggesting 
metastases, had not had the testing at issue in the past and was seeking treatment. This testing is used to better 
match medication options to the patient using gene testing. The enrollee appears to meet the criteria for this 
testing at this time. Therefore, the testing was medically necessary based on the provided documentation. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the Caris Molecular Intelligence(r) testing rendered on January 14, 2022.  
 
Local Coverage Determination (LCD) L36256 referenced by the Plan does not provide coverage criteria for the 
services at issue and was not used in the MAXIMUS determination.  
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: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 5, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a Medicare 
benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the gene panel at issue includes the FANCC 
gene. Panels of tests that include this gene are statutorily excluded. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on January 5, 2022.
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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 appears to be more stable and should only require short-term additional 
acute care services that can safely be provided at the current facility until more appropriate for a lower 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 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 pre-approve eight additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that these services have been helping your 
condition tremendously. The Plan denied your request. The Plan says the requested therapy services are not 
medically necessary in this case. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the clinical documentation provided by the physical therapist states 
that you have hit a rehab plateau. There is no documentation as to why you would require the skill of a 
professional therapist for maintenance of your clinical status. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eight additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it seems as though IGRT appears to being offered as routine practice, and as there does not seem to 
be any exceptional circumstances with this patient necessitating the need for IGRT. For radiation in the 
palliative setting, IGRT could be considered medically necessary when it is necessary to escalate the dose (i.e. 
oligometastases), particularly when using very high dose per fraction, or when critical normal tissues abutting 
the target necessitate daily image guidance to allow minimal planning margins to spare the normal tissue.  In 
this case, the intent is clearly palliative, and it is not clear what benefit IGRT would afford. There is no specific 
justification provided for the need for IGRT. 
 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 13, 2021, to April 
18, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient care at the DRG originally billed. You say that You did not provide 
a specific argument with your appeal request. The Plan denied your request. The Plan says the secondary 
diagnosis of G93.41 (metabolic encephalopathy) is not supported by the medical record. 
 
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 a secondary diagnosis of G93.41 (metabolic 
encephalopathy). 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 care at the 
DRG originally billed. Our reviewer says that the secondary diagnosis of G93.41 (metabolic encephalopathy) is 
not supported by the medical record. Our physician reviewer found the documentation did support an 
admission for E87.2 Acidosis. From the information that was received, the documentation was inconsistent/ 
unclear regarding a diagnosis of Metabolic encephalopathy. Even though metabolic encephalopathy was 
documented in the progress notes, supporting medical record documentation was not found within the record. 
Patient presented to the emergency room (ER) with confusion per his wife. The patient's baseline was alert and 
oriented X 4. On presentation, the patient was noted to be alert and oriented X4. The patient had a history of 
chronic spinal cord injury with severe spasticity. The medical record notes "Acute metabolic encephalopathy, 
multifactorial, improved; likely due to urinary tract infection and azotemia, metabolic acidosis, concurrent use 
of Ativan/Fentanyl in ER leading to somnolence." A computed tomography scan of the head showed no 
evidence of acute intracranial hemorrhage, acute hydrocephalus, or significant midline shift. While the patient 
presentation warranted consideration of metabolic encephalopathy as possible diagnosis, there was no evidence 
of neurological symptoms documented by the provider to be beyond the member's baseline, diagnostic work up 
and treatment to address diagnosis of encephalopathy.  
 
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 care provided from April 13, 2021, to April 18, 2021, at the Diagnosis Related Group 
(DRG) originally billed.