Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request is not medically necessary, the services you need can be provided safely 
in other settings, for example, a skilled nursing facility. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that patient has complex functional impairments and active medical 
comorbidities thus it would be expected for patient to require inpatient hospitalization with an interdisciplinary 
approach to rehabilitation 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 Rebyota Enema 150ML. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says you must have had a trial of bezlotoxumab (Zinplava) with an 
inadequate response, significant side effect/toxicity, or have a contraindication to this therapy (please note, 
Zinplava also requires prior authorization). 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug bezlotoxumab (Zinplava) with an inadequate response, significant side 
effect/toxicity, or have a contraindication to this therapy, before the Plan will approve the requested drug. In 
this case, you have not tried and failed the required drug(s). There is no documentation provided indicating that 
the Plans required drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rebyota Enema 150ML.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasopharyngoscopy, surgical, with dilation of 
eustachian tube bilateral (69760). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested service 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 surgical service. Our reviewer says 
that the requested surgical service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy of the requested 
surgical service for the enrollee's clinical condition. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer 
found that the requested surgical service is 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve nasopharyngoscopy, surgical, with dilation of eustachian tube bilateral (69760).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 26, 2022.
You asked the Plan to pay for this testing. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial for insufficient information in the file. The Plan
requested a reopen and provided additional information. The Plan noted that a review of the claim shows that
the provider did not bill with the required unique test identifier or DEX-Z-code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim could
not be paid as billed due to the omission of the required identifier code. Medicare rules for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided
to the enrollee on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation shows that you are only using insulin once daily. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 2 sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (37225, 36247, 37186, 75710) provided on 
October 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable.  
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 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 use of code 37225 is 
not supported by the records provided. Our reviewer found that the medical record does not include a 
procedure report for date of service October 13, 2022, only anesthesia and post-op instructions were found. 
 
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. 
 
In this case, we have also confirmed that codes 36247, 37186, and 75710 are column II codes to column I code 
37229. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (37225, 36247, 37186, 75710) provided on October 13, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not indicate ongoing daily skilled needs and the enrollee's needs can be met with home health services.
Our Medical director looked at the case file and the reopen request. At issue is coverage for SNF care. Our Medical Director states that there are no required skilled nursing services identified. The documentation does not support that it is medically reasonable and necessary to provide skilled services on a daily basis. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Onivyde. 
 
You asked the Plan to pre-approve Onivyde. 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 Onivyde. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Onivyde is 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 Onivyde have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Onivyde.
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.  There are no pulmonary function tests to assess 
the severity of the COPD. There is no arterial blood gas done while stable to document 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 15, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 
70553. 
 
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, we have confirmed that code 70544 
is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service October 25, 
2022.
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 a home ventilator is not medically 
necessary. If this enrollee does have chronic carbon dioxide (CO2) retention, may benefit from bilevel positive 
airway pressure (BiPAP) with average Volume Assured Pressure Support (AVAPS) during sleep as an 
outpatient. This has not been tried and failed. 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CFTR (cystic fibrosis transmembrane conductance regulator) 
gene analysis; full gene sequence (81223), F9 (coagulation factor IX), full gene sequence (81238) and FXN 
(frataxin) gene analysis; full gene sequence (81286) provided on June 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and are requesting 
reconsideration of payment. The Plan denied your request. The Plan says the requested services are considered 
to be experimental or investigational and are excluded from coverage under the enrollee's plan. 
 
The Plan follows Medicare rules. The rules say that there is a list of tests that are unlikely to impact therapeutic 
decision-making, directly impact treatment, outcome and/or clinical management in the care of the enrollee and 
will be denied as not medically necessary. 
 
The tests at issue in this appeal, CFTR, FXN and F9, are listed as not medically necessary. Medicare does not 
cover these tests that are unlikely to impact therapeutic decision-making, directly impact treatment, outcome 
and/or clinical management in the care of the beneficiary and will be denied as not medically necessary.. 
Therefore, we decided that the Plan does not have to pay for CFTR (cystic fibrosis transmembrane conductance 
regulator) gene analysis; full gene sequence (81223), F9 (coagulation factor IX), full gene sequence (81238) 
and FXN (frataxin) gene analysis; full gene sequence (81286) provided on June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2021, to 
September 14, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the acute inpatient hospital care at 
issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for 
payment for acute inpatient hospital care have not been met. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record shows that, at the time of inpatient admission, the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 12, 2021, to September 14, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9567 billed for date of service August 24, 
2022. 
 You asked the Plan to pay for procedure code A9567. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code A9567 is 2. The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code A9567 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A9567 billed for date of service August 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (durvalumab) 10MG injection (J9173) and 
Onivyde (irinotecan liposome) 1MG injection (J9205). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the use of for Onivyde and Imfinzi for metastatic biliary tract cancer is 
not FDA approved or listed in the Medicare approved sources. 
 
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 the medication. Our physician reviewer 
found no literature or compendia support for liposomal irinotecan and Imfinzi in biliary cancer. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Imfinzi (durvalumab) 10MG injection (J9173) and Onivyde (irinotecan liposome) 1MG 
injection (J9205).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oscillatory positive expiratory pressure device, non-
electric, any type, each (Acapella device) (E0484). 
 
You asked the Plan to pre-approve Acapella device. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says the requested device 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 Acapella device. Our reviewer says that 
the requested Acapella device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates that you have a productive cough. The reviewer found 
that the medical documentation provided does not document the duration of the cough or its productivity, and 
the notes do not address a need for airway clearance. The reviewer also found there is no documentation that 
pulmonary physiotherapy has been tried and failed or cannot be done. Therefore, the reviewer found that the 
requested Acapella device is not medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Acapella device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve oscillatory positive expiratory pressure device, non-electric, any type, each (Acapella 
device) (E0484).